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[Note: This report was revised on January 27, 2012, to change $52.5 
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references to annual reports on pages 9 and 26 were clarified] 

United States Government Accountability Office: 
GAO: 

Report to the Chairman and Ranking Member, Committee on Armed 
Services, House of Representatives: 

January 2012: 

Defense Health: 

Coordinating Authority Needed for Psychological Health and Traumatic 
Brain Injury Activities: 

GAO-12-154: 

GAO Highlights: 

Highlights of GAO-12-154, a report to the Chairman and Ranking Member, 
Committee on Armed Services, House of Representatives. 

Why GAO Did This Study: 

Post-traumatic stress disorder (PTSD), which falls into the broader 
field of psychological health (PH), and traumatic brain injury (TBI) 
are recognized as the signature wounds of the wars in Afghanistan and 
Iraq. In two reports issued in 2011 (GAO-11-219 and GAO-11-611), GAO 
cited numerous management weaknesses at the Defense Center of 
Excellence for PH and TBI (DCOE). For the present report, GAO reviewed 
(1) funding for DOD's PH and TBI activities in fiscal years 2007 
through 2010 and the accuracy of its reporting on these activities to 
Congress and (2) DOD's ability to coordinate its PH and TBI activities 
to help ensure that funds are used to support programs of the most 
benefit to service-members. GAO interviewed DOD officials, reviewed 
legislation and DOD’s annual reports, and obtained relevant 
documentation. 

What GAO Found: 

What GAO Found
From fiscal year 2007 through fiscal year 2010, DOD activities for the 
treatment and research of PH and TBI received more than $2.7 billion. 
In fiscal year 2007, funding for these activities totaled $900 
million; in fiscal year 2008, it was $573.8 million; in fiscal year 
2009, $395 million; and in fiscal year 2010, $838.6 million. GAO 
found, however, that the reports DOD provided to Congress on these 
activities did not include expenditures, as required by law, and that 
the obligations data they contained were unreliable. Governmentwide 
policies call for agencies to have effective internal controls to 
assure accurate reporting of obligations and expenditures. However, 
the Office of the Assistant Secretary of Defense for Health Affairs 
has not developed quality control mechanisms to help ensure that data 
on PH and TBI activities are complete and accurate. Further, although 
DOD listed patient care among reported costs, it did not specify what 
those costs included, making it difficult for decisionmakers and 
Congress to fully understand the costs. 

No one organization coordinates DOD’s PH and TBI activities. The 
National Defense Authorization Act for Fiscal Year 2008 directed the 
Secretary of Defense to establish a Center for PTSD and a Center for 
TBI to, among other things, implement DOD’s comprehensive plans for 
these issues, disseminate best practices, provide guidance, and 
conduct research. Subsequently, a Senior Oversight Committee 
established by the Secretaries of Defense and Veterans Affairs 
reported in its plan to Congress that DOD had created a single Defense 
Center of Excellence for PH and TBI (DCOE) to lead efforts in practice 
standards, training, outreach, research, and direct care. The 
Committee tasked DCOE with acting as an information clearinghouse that 
would allow servicemembers and their families to navigate the system 
of care. In its own plan, DCOE stated that it would serve as a 
coordinating authority for DOD's PH and TBI issues and perform a gap 
analysis to identify needed programming. GAO found, however, as it had 
in prior reports, that DCOE’s strategic plan did not reflect a clear 
mission focusing the organization on its statutory responsibilities. 
Instead, those responsibilities are dispersed among the TRICARE 
Management Activity, the Army Medical Research and Materiel Command, 
and others. While the Office of the Assistant Secretary of Defense for 
Health Affairs has broad oversight for all of DOD’s medical missions, 
its global role prevents it from focusing on PH and TBI activities 
specifically. As a result, no single organization is devoted to 
ensuring that accurate and timely data are available on DOD’s PH and 
TBI activities or coordinating these activities. GAO, in conducting 
this review, had to obtain information from several different sources 
to compile a comprehensive list of DOD's PH and TBI activities. This 
finding was echoed in a recent RAND report that also noted that no 
single source in DOD tracked its PH and TBI programs or had 
appropriate resources to direct servicemembers to the full array of 
programs available. Without an entity to coordinate these activities, 
DOD will remain hampered in its efforts to ensure that resources are 
used effectively to meet goals, and Congress will be limited in its 
ability to obtain reliable information to guide decisionmaking. 

What GAO Recommends: 

GAO recommends that DOD direct the Assistant Secretary of Defense for 
Health Affairs to (1) include expenditure data in annual reports to 
Congress, as required; (2) establish quality control mechanisms on PH 
and TBI data; (3) if patient care costs are provided in future annual 
reports, specify what they include; and (4) revisit DCOE’s role as 
DOD’s coordinating authority for issues concerning PH and TBI, as 
stated in DCOE’s campaign plan, and determine whether DCOE or another 
organization should perform this function. In written comments on a 
draft of this report, DOD concurred with all four recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-12-154] or key 
components. For more information, contact Brenda S. Farrell at (202) 
512-3604 or farrellb@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

More Than $2.7 Billion in Appropriated Funds Supported DOD Treatment 
and Research Activities Related to PH and TBI: 

Multiple Entities Play Roles in PH and TBI Activities, but None Serves 
as Coordinating Authority: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Responsibilities for the Defense Centers of Excellence as 
Detailed in the National Defense Authorization Act for Fiscal Year 
2008: 

Appendix III: RDT&E-Funded Projects: 

Appendix IV: Examples Provided by the Army Medical Research and 
Materiel Command of Ongoing Research That Was Representative of 
Positive Results Achieved to Date: 

Appendix V: Comments from the Department of Defense: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Defense Components with Roles Addressing PH and TBI: 

Table 2: RDT&E-funded Projects Addressing PH and TBI: 

Figures: 

Figure 1: Defense Center of Excellence for Psychological Health and 
Traumatic Brain Injury Alignment within DOD: 

Figure 2: System Anticipated from the Army's Biomarker Assessment: 

Figure 3: Brain Imagery Demonstrating the Impact of Treatment with NNZ-
2256: 

Figure 4: Differences among CT, Routine MRI, and Advanced Protocol MRI 
Scans: 

Abbreviations: 

DCOE: Defense Center of Excellence for Psychological Health and 
Traumatic Brain Injury: 

DOD: Department of Defense: 

O&M: Operation and Maintenance: 

PH: psychological health: 

PTSD: Post-Traumatic Stress Disorder: 

RDT&E: Research, Development, Test and Evaluation: 

TBI: Traumatic Brain Injury: 

TMA: TRICARE Management Activity: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

January 25, 2012: 

The Honorable Howard P. McKeon:
Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives: 

Public concern over health care issues confronting servicemembers 
returning from the wars in Afghanistan and Iraq has grown considerably 
over the past several years. Most recently, concerns have centered on 
two injuries--post-traumatic stress disorder (PTSD) and traumatic 
brain injury (TBI)--which are referred to as the "signature wounds" of 
these wars. TBI is defined as a traumatically induced structural 
injury or physiological disruption of brain function resulting from 
external force. TBI can vary greatly in terms of severity--from mild 
cases that might involve a brief change in mental status, such as 
being dazed or confused, to severe cases that may involve an extended 
period of unconsciousness or amnesia after the injury. Brain injuries 
are classified as mild, moderate, severe, or penetrating, based on 
factors associated with the initial injury, such as the length of time 
the patient spent in a coma, rather than on the symptoms or long-term 
effects. 

In the wake of the February 2007 disclosure of deficiencies in 
outpatient services at the Walter Reed Army Medical Center following 
an investigation by the Washington Post,[Footnote 1] various review 
groups, task forces, and presidential commissions investigated the 
care and benefits provided to servicemembers and veterans by the 
Department of Defense (DOD) and the Department of Veterans Affairs. 
[Footnote 2] In May 2007, Congress passed a supplemental appropriation 
that included funding for the treatment of PTSD and TBI.[Footnote 3] 
In the National Defense Authorization Act for Fiscal Year 2008, 
Congress directed DOD to establish Defense Centers of Excellence for 
the prevention, diagnosis, mitigation, treatment, and rehabilitation 
of post-traumatic stress disorder and other mental health conditions, 
as well as traumatic brain injury.[Footnote 4] 

Consistent with your oversight responsibility, you requested GAO to 
determine how much funding had been used to support DOD PH and TBI 
activities in recent years and how those funds had been used. 
Specifically, you requested that we review the following: 

(1) DOD's funding for PH and TBI activities in fiscal years 2007 
through 2010, as well as the accuracy of DOD's reported obligations 
and expenditures for PH and TBI in its required annual reports to 
Congress; and: 

(2) DOD's ability to coordinate its PH and TBI activities to help 
ensure that funds are used to support activities of the most benefit 
to servicemembers. 

To determine the amount of appropriated funds that supported 
activities related to PH and TBI for fiscal years 2007 through 2010, 
we reviewed DOD appropriations acts and accompanying committee reports 
from fiscal years 2007 through 2010, and we interviewed and obtained 
documentation from officials with the Office of the Assistant 
Secretary of Defense for Health Affairs; the TRICARE Management 
Activity's[Footnote 5] Office of the Chief Financial Officer, which 
manages operation and maintenance (O&M) and procurement funds; and the 
Army Medical Research and Materiel Command, which manages research, 
development, test and evaluation (RDT&E) funds. To determine how 
accurately DOD has been reporting obligations and expenditures for PH 
and TBI in required annual reports to Congress, we reviewed and 
analyzed DOD's annual reports to Congress on expenditures for these 
activities for calendar years 2008, 2009, and 2010 and compared 
information contained in these reports to documentation we obtained 
from the TRICARE Management Activity, the Army Medical Research and 
Materiel Command, and the individual military services. Through our 
assessment of data provided by DOD, as well as the assessments of 
previous GAO reviews,[Footnote 6] we determined that data on reported 
PH and TBI obligations were unreliable. However, we also determined 
that, because these data are used by DOD and the military services to 
manage their operations, it was appropriate to use these data as a 
starting point for our analysis. Data reliability issues are discussed 
throughout the report, as applicable. Moreover, our findings and 
recommendations address the need for DOD to address data reliability 
weaknesses. 

To evaluate DOD's ability to coordinate its PH and TBI activities to 
help ensure that funds are used to support activities of greatest 
benefit to servicemembers, we interviewed officials with the Office of 
the Assistant Secretary of Defense for Health Affairs, which oversees 
DOD's medical and dental programs; the TRICARE Management Activity; 
the Defense Center of Excellence for Psychological Health and 
Traumatic Brain Injury (DCOE); and the Army Medical Research and 
Materiel Command. In addition, we reviewed the legislation 
establishing different organizations with responsibilities for 
overseeing PH and TBI, i.e., DCOE; the DOD/VA Wounded, Ill, and 
Injured Senior Oversight Committee; the Joint Executive Committee; and 
the Armed Services Biomedical Research Evaluation and Management 
Committee. We analyzed the documents generated by these organizations 
to provide guidance and oversight of PH and TBI activities. 

We conducted this performance audit from June 2010 through January 
2012 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. For 
additional information on our scope and methodology, see appendix I. 

Background: 

Congress typically provides funding for the Defense Health Program 
appropriation, including funding for PH and TBI activities, in annual 
defense appropriations. For its fiscal year 2012 budget request, DOD 
requested $52.5 bllion to provide health care to approximately 9.6 
million active-duty servicemembers, reservists, retirees, and their 
dependents. This funding includes O&M, RDT&E, and procurement. 
[Footnote 7] O&M generally covers the hiring and payment 
of civilian providers, along with operation costs for running 
hospitals and other facilities. RDT&E generally covers research and 
development efforts. Procurement covers acquisition expenses. The 
Defense Health Program's O&M funds are generally available for 
obligation for 1 fiscal year, subject to certain exceptions.[Footnote 
8] RDT&E funds are generally available for obligation for 2 fiscal 
years, while procurement funds are generally available for obligation 
for 3 fiscal years. 

Within DOD, the Office of the Assistant Secretary of Defense for 
Health Affairs oversees the Military Health System, a global medical 
network that provides health care to all U.S. military personnel 
worldwide. The Military Health System comprises over 133,000 military 
and civilian doctors, nurses, medical educators, researchers, 
healthcare providers, allied health professionals, and health 
administration personnel. The Assistant Secretary of Defense for 
Health Affairs oversees the development of medical policies, analyses, 
and recommendations to the Secretary of Defense and the Undersecretary 
for Personnel and Readiness, and issues guidance to DOD components on 
medical matters. The Assistant Secretary also serves as the principal 
advisor to the Undersecretary for Personnel and Readiness on matters 
of chemical, biological, radiological, and nuclear medical defense 
programs and deployment matters pertaining to force health. Providing 
broad oversight for PH and TBI matters is only one element among the 
Assistant Secretary's comprehensive responsibilities. Within the 
Office of the Assistant Secretary of Defense for Health Affairs, the 
Office of Force Health Protection and Readiness coordinates and 
transmits information on PH and TBI activities to Congress on behalf 
of DOD. The Office of the Assistant Secretary of Defense for Health 
Affairs also serves as director of the TRICARE Management Activity, 
which oversees DOD's medical and dental programs and manages and 
executes the Defense Health Program appropriation. TRICARE Management 
Activity's associated programs, resources, and functions include the 
Uniformed Services University of the Health Sciences, the Armed Forces 
Radiobiology Research Institute, and the Defense Center of Excellence 
for Psychological Health and Traumatic Brain Injury (DCOE). 

Figure 1 presents an organizational chart that shows the current 
alignment of the organizations involved in managing DOD's PH and TBI 
activities. The TRICARE Management Activity manages and executes 
Defense Health Program O&M and procurement funding for PH and TBI; the 
Army Medical Research and Materiel Command manages and executes the 
majority of Defense Health Program RDT&E funding for PH and TBI; and 
each military service also uses Defense Health Program O&M funds 
distributed to them for PH and TBI activities. 

Figure 1: Defense Center of Excellence for Psychological Health and 
Traumatic Brain Injury Alignment within DOD: 

[Refer to PDF for image: illustration] 

Office of the Secretary of Defense: 
* Navy; 
* Army: 
Army Medical Research and Materiel Command; 
* Air Force; 

Under Secretary of Defense for Personnel and Readiness: 
* Assistant Secretary of Defense (Health Affairs)/Director, TRICARE 
Management Activity; 
* Defense Centers of Excellence for Psychological Health and Traumatic 
Brain Injury. 

Source: GAO analysis of DOD data. 

[End of figure] 

In two reports that we issued in 2011, we cited numerous management 
weaknesses at DCOE, as well as unreliable reporting of how DOD was 
obligating Defense Health Program O&M funds for the treatment of and 
research on servicemembers experiencing PH-and TBI-related problems. 
[Footnote 9] The National Defense Authorization Act for Fiscal Year 
2008 required DOD to create centers of excellence for PTSD and other 
mental health conditions, and for TBI.[Footnote 10] Congress tasked 
these centers of excellence with numerous responsibilities, to include 
providing for the development, testing, and dissemination of best 
practices within DOD for the treatment of PTSD and TBI. In response, 
DOD established DCOE as the one entity intended to lead DOD's effort 
to develop excellence in its prevention, outreach, and care for those 
with these conditions. 

In our February 2011 report, we discussed challenges facing DCOE as it 
was being developed. We found that DCOE's lack of mission clarity 
hampered its ability to move forward and that its strategic plan had 
two areas of weakness that did not conform to best practices. 
Specifically, the plan's management reviews--intended to align 
activities, resources, and goals--were insufficient to ensure that its 
daily activities were aligned with its mission and goals; and the plan 
did not fully describe how meeting its performance measures would help 
DCOE assess attainment of its goals. We further found that the TRICARE 
Management Activity, which administered funds allocated to DCOE, had 
not developed written policies and procedures to ensure the proper 
recording of obligations and that it had not properly classified most 
of DCOE's fiscal year 2009 contract obligations. We recommended that 
DCOE take steps to improve its strategic plan and that the TRICARE 
Management Activity develop, implement, and maintain written 
procedures for the proper classification and recording of DCOE 
obligations. DOD concurred with our recommendations. 

In our June 2011 report we reviewed DCOE's budget formulation process 
and the availability of information about DCOE to Congress. We found 
that DCOE's role in the DOD budget formulation process was limited to 
consolidating component centers' budget requests and providing them to 
the TRICARE Management Activity. Further, these budget requests did 
not include complete narrative justifications. Like the February 
report, this one found that DOD had not clearly defined DCOE's 
mission. This report also found that because DCOE is a relatively 
small entity funded primarily through the larger Defense Health 
Program appropriation, it falls below the most detailed level that is 
presented in congressional budget presentation materials; 
additionally, DOD is not required to report separately on DCOE. We 
recommended that the TRICARE Management Activity work with DCOE to 
develop and use additional narrative in budget justifications and 
regularly collect and review data on funding and obligations. DOD 
concurred with these recommendations. 

More Than $2.7 Billion in Appropriated Funds Supported DOD Treatment 
and Research Activities Related to PH and TBI: 

Funding Totaled More Than $2.7 Billion: 

From fiscal year 2007 through fiscal year 2010, DOD activities 
relating to the treatment and research of PH and TBI received more 
than $2.7 billion. Funding for PH and TBI was derived from specific 
appropriations and congressionally directed amounts drawn from Defense 
Health Program O&M; procurement; and RDT&E appropriations.[Footnote 
11] During this period, Congress appropriated $675 million 
specifically for PH and TBI, and more than $2 billion was drawn from 
Defense Health Program accounts for activities related to PH and TBI. 
[Footnote 12] In fiscal year 2007, total appropriations of $900 
million supported PH and TBI activities. In fiscal year 2008, total 
funding was $573.8 million. In fiscal year 2009, total funding was 
$395 million. In fiscal year 2010, appropriations totaled $838.6 
million. 

DOD-Provided Data in Annual Reports to Congress on PH and TBI Are 
Incomplete and Unreliable: 

Annual reports submitted to Congress by DOD on amounts expended on PH 
and TBI have been incomplete; data on reported obligations are 
unreliable; and, in calculating the cost of medical care for patients 
with PH and TBI, DOD has not clearly stated what is and is not 
included in these figures, making it difficult to arrive at a 
comprehensive cost for DOD’s PH and TBI activities. Section 1634 of 
the National Defense Authorization Act for Fiscal Year 2008 requires 
the Secretary of Defense to submit an annual report setting forth the 
amounts DOD expended during the preceding calendar year on activities 
relating to the diagnosis, treatment, and rehabilitation of 
servicemembers with PH (to include PTSD) or TBI concerns.[Footnote 13]
Section 1634 further directs DOD to submit reports annually through 
2013, with the first report being due no later than March 1, 2008. The 
Office of Force Health Protection and Readiness within the Office of 
the Assistant Secretary of Defense for Health Affairs coordinates and 
transmits this report to Congress on behalf of DOD and works in 
conjunction with the Office of the Chief Financial Officer, TRICARE 
Management Activity, to obtain the requested amounts. DOD has 
submitted four of these annual reports thus far. The first report was 
submitted on May 1, 2008; two reports for calendar year 2009 were 
submitted, one on June 30, 2009, and one on June 29, 2010; and the 
report for calendar year 2010 was submitted on May 10, 2011.

Our analysis of all four reports showed that, while the reports 
included information about reported obligations, they did not include 
expenditure data--as required by the law. Officials in the Office of 
the Assistant Secretary of Defense for Health Affairs, who are 
responsible for compiling and transmitting the reports, said that they 
had intentionally reported amounts obligated instead of amounts 
expended for two reasons: first, expenditures are recorded later, and 
second, obligation figures are more representative of current costs, 
which they interpreted to be Congress's primary interest. In response 
to the issues raised by our review, these officials said that in 
future reports they would provide an explanation of why the only 
figures reported are amounts obligated. While we recognize DOD's 
position on this matter, we note that reporting only amounts obligated 
is not fully consistent with the statute. Furthermore, in the absence 
of expenditure data, Congress will not have a complete accounting of 
the cost of PH or TBI activities. 

In all four reports, DOD presented general information on activities 
and associated amounts reported as having been obligated for PH and 
TBI. DOD also included the estimated number of patients served and the 
estimated costs for PH and TBI patient diagnosis and care. Beyond 
that, in responding to its annual reporting requirement, DOD pursued 
different approaches in its four annual reports. Accordingly, the 
types of information DOD presented varied each year. In its initial 
report, DOD identified spending plans and reported obligations for 
fiscal year 2008 O&M and RDT&E funds as of February 29, 2008. The 
first report provided general information on reported monthly O&M 
obligations across the six categories of civilian pay, travel, 
contracts, supplies, equipment, and other. The report also contained 
reported monthly obligations of RDT&E funds divided between PH and 
TBI. In contrast, the second, third, and fourth reports displayed 
funding data for reported O&M obligations according to the strategic 
initiatives of access to care, quality of care, resilience, 
transition, screening and surveillance, and leadership and advocacy. 
All reported RDT&E obligations were listed under the strategic 
initiative of research. The second, third, and fourth reports also 
described progress achieved to date and planned activities in the 
upcoming year for each strategic initiative. Absent from the third 
report was any discussion of procurement dollars, even though the 
summary table showed that $20 million had been appropriated for 
Defense Health Program procurement in fiscal year 2009. 

We found, however, that the O&M funding data that DOD provided for all 
four reports on PH and TBI activities are not reliable. As noted 
earlier, we reported in 2011 that we could not confirm the accuracy of 
O&M figures for DCOE and that we had unresolved concerns about the 
reliability of funding and obligations data provided by TRICARE 
Management Activity.[Footnote 14] In the present study, we have again 
found that O&M figures for DCOE and funding and obligations data 
provided by TRICARE Management Activity are unreliable.[Footnote 15] 

This lack of reliability is attributable to DOD's not having a 
coordinated mechanism enabling it to confirm the reliability of data 
maintained by the different databases used in reporting PH-and TBI-
related funding. The Assistant Secretary of Defense for Health Affairs 
does not obtain needed data from one source; rather, in order to 
comprehensively identify DOD PH and TBI funding and projects, that 
office must assemble and integrate data obtained from several 
entities. Officials from the Office of the Secretary of Defense for 
Health Affairs obtain funding data from various information systems 
that are maintained by the TRICARE Management Activity, the services, 
and the Defense Finance and Accounting Service. To track PH and TBI 
activities funded with O&M dollars, TRICARE Management Activity 
officials use an internal, Web-based information system that extracts 
and aggregates funding data from the internal TRICARE Management 
Activity system as well as the individual service components' systems. 
TRICARE Management Activity officials said that they could confirm the 
reliability only of information extracted from their own internal 
TRICARE Management Activity system and that they rely on the services' 
PH/TBI program management offices to ensure the completeness and 
accuracy of the services' data. The TRICARE officials directed us to 
communicate directly with the respective services' PH/TBI program 
management offices regarding the completeness and accuracy of the 
services' data. Service program management and information system 
management officials in turn told us that their internal data systems 
were subcomponents of multiple military departmentwide financial 
management systems. For example, Army officials explained that to 
track Defense Health Program RDT&E funds, the Army Medical Research 
and Materiel Command, must rely on three separate servicewide systems--
the Standard Army Finance Information System, the Standard Operation 
and Maintenance Army Research and Development System, and the General 
Fund Enterprise Business System--to maintain visibility over relevant 
funding.[Footnote 16] 

We have identified internal control[Footnote 17] as a major part of 
managing an organization and providing reasonable assurance that an 
agency will produce reliable financial reporting, such as reports on 
budget execution, financial statements, and other reports for internal 
and external use. One of the standards for internal control entails 
the proper execution of transactions and events, accurate and timely 
recording of transactions and events, and controls over information 
processing. This standard includes a process for confirming 
completeness, accuracy, authorization, and validity of all 
transactions during processing. 

TRICARE Management Activity officials acknowledged having a 
shortcoming in meeting the internal control standard for confirming 
completeness and accuracy in data and indicated that the Activity is 
moving to integrate its financial management systems. Until the Office 
of the Assistant Secretary of Defense for Health Affairs establishes 
quality control mechanisms coordinated specifically to address the 
collection and reporting of data related to PH and TBI activities 
maintained on DOD's and the services' various financial information 
management systems, Congress and others cannot be assured when using 
DOD's annually reported obligation and expenditure data that they are 
complete and accurate. 

In addition, DOD includes in its annual reports the estimated costs of 
caring for patients with PH and TBI, but it does not clearly inform 
readers which costs they can expect to find included in these reports. 
For example, the first report states that the full costs of caring for 
PH and TBI are contained in multiple appropriations, yet the report 
includes only the costs from the Defense Health Program's 
appropriation. As another example, the report states that the scope of 
psychological health is very broad and includes programs ranging from 
preclinical to transitional health programs and services, as well as 
family, leadership, and community education and training. However, DOD 
does not include the costs for these programs, and DOD's calculation 
of patient care includes only care for servicemembers who deployed to 
Afghanistan or Iraq. Also, although DOD states that patient care costs 
include "direct care and purchased care," it does not define these 
terms. In particular, it is not clear whether "direct care" includes 
the salaries of military medical personnel. As a result, it is not 
clear which patient care costs should be added to reported O&M, RDT&E, 
and procurement obligations to arrive at a comprehensive cost for 
DOD's PH and TBI activities. If DOD continues to provide a calculation 
of patient care costs in its annual reports without a clear 
explanation of what is and is not included in its calculation, DOD 
decisionmakers and Congress will not have information needed to enable 
them to make a complete assessment of how much it costs to provide PH 
and TBI-related activities. 

Small Percentage of PH and TBI Projects Accounted for Preponderance of 
O&M Funding: 

In light of the shortcomings of the reported O&M obligation data that 
TRICARE Management Activity provided to us, we requested obligation 
information on DOD's O&M-and procurement-related PH and TBI projects 
directly from the military services' PH/TBI program management offices 
for the 2 years for which data were available--fiscal years 2009 and 
2010.[Footnote 18] We determined that it was appropriate to use this 
project information for the purposes of this review because these are 
the data that DOD and the services use to manage their operations. 
[Footnote 19] According to the service program management offices' 
databases, 177 separate PH and TBI projects were funded with O&M funds 
in fiscal years 2009 and 2010: 152 in fiscal year 2009 and 133 in 
fiscal year 2010.[Footnote 20] For both years, a small percentage of 
these projects accounted for the preponderance of reported obligation 
funds. For example, according to Army data, the Army undertook 71 and 
52 projects in fiscal years 2009 and 2010, respectively. Of those 
projects, four accounted for more than half of its O&M-funded projects 
in both fiscal years. The four projects were designed to increase TBI 
care capabilities at six regional medical centers; to supplement 
rehabilitation capabilities at 16 facilities with large troop 
populations; and to hire additional behavioral health practitioners. 
According to Army data, prior to fiscal year 2007, each mental health 
practitioner had approximately 6.5 sessions per patient; by fiscal 
year 2010, each practitioner had an average of 8 sessions per patient. 
Similarly, 4 of the Navy's 63 projects accounted for more than 50 
percent of its reported Defense Health Program O&M-funded obligations 
in fiscal years 2009 and 2010.[Footnote 21] The four projects focused 
on hiring staff and purchasing equipment and supplies to support 
timely access to PH and TBI health care; on a family support program 
to promote family unit cohesion following a servicemember's high-risk 
deployments; and on developing curriculums for service primary care 
providers to expand their knowledge of mental health services. Lastly, 
Air Force data indicate that 3 of its 18 projects accounted for less 
than 80 percent of its reported obligations for Defense Health Program 
O&M funding in fiscal years 2009 and 2010. That service's projects 
entailed the recruitment, qualification, and retention of health care 
workers at service medical treatment facilities both inside and 
outside the United States. We could not complete a similar analysis of 
O&M obligations for fiscal years 2007 and 2008, as the data for those 
years were unavailable. The services have used procurement funds to 
purchase computed tomography scanning[Footnote 22] and magnetic 
resonance imaging equipment to aid in the diagnosis and treatment of 
servicemembers with traumatic brain injuries. 

Army and Defense Health Program RDT&E Funding Evenly Divided Between 
Clinical and Non-Clinical Projects: 

The Army Medical Research and Materiel Command, which has visibility 
over Army and Defense Health Program RDT&E-funded work for PH and TBI, 
identified 397 projects that were underway during fiscal years 2007 
through 2009; data for all of fiscal year 2010 were unavailable at the 
time of our data request. Sixty-six percent of the 397 projects were 
Research and Technology Development (nonclinical) projects. These 
types of studies form the knowledge-and technology-based foundation 
necessary to establish the initial feasibility and practicality of 
proposed solutions to problems. The remaining 34 percent of the 397 
projects were Clinical Research and Development--projects that are 
typically conducted in a clinical setting using human research 
volunteers (including patients) and are directed at amassing the 
definitive level of evidence required to inform changes in medical 
practice or required for licensure of a product regulated by the Food 
and Drug Administration. Although there were twice as many nonclinical 
as there were clinical projects, dollars awarded were distributed 
fairly evenly between these two types. See appendix III for a listing 
of the 397 RDT&E projects, and see appendix IV for descriptions of 
three examples the Army highlighted as representative of positive 
results achieved to date. 

Multiple Entities Play Roles in PH and TBI Activities, but None Serves 
as Coordinating Authority: 

No one organization coordinates DOD's PH and TBI activities. The 
National Defense Authorization Act of Fiscal Year 2008 directed the 
Secretary of Defense to establish a Center of Excellence for PTSD and 
other mental health conditions and a second Center of Excellence for 
TBI and directed those Centers to, among other things, implement DOD's 
comprehensive plans for these issues, disseminate best practices, 
provide guidance, and conduct research. (For a complete listing of the 
responsibilities assigned to the Centers in this legislation, see 
appendix II.) Subsequently, a Senior Oversight Committee established 
by the Secretaries of Defense and Veterans Affairs reported in its 
comprehensive plan to Congress that DOD had combined these two Centers 
into one DCOE for PH and TBI to lead efforts in practice standards, 
training, outreach, research, and direct care. We found, however, as 
we had in prior reports, that DCOE's strategic plan did not reflect a 
clear mission that focused the organization on its statutory 
responsibilities. Instead, responsibilities are dispersed among the 
TRICARE Management Activity, the Army Medical Research and Materiel 
Command, and others. While the Office of the Assistant Secretary of 
Defense for Health Affairs has broad oversight for all of DOD's 
missions, its global role prevents it from focusing on PH and TBI 
activities specifically. 

Defense Center of Excellence for PH and TBI Was Directed to Implement 
DOD's Comprehensive Plans for PH and TBI: 

The National Defense Authorization Act for Fiscal Year 2008 directed 
the establishment of Defense Centers of Excellence to address the 
prevention, diagnosis, mitigation, treatment, and rehabilitation of 
PTSD and TBI and other mental health conditions.[Footnote 23] In the 
legislation, Congress enumerated 10 responsibilities for the Center 
dedicated to PTSD and other mental health conditions and 13 
responsibilities for the Center dedicated to TBI. Among other things, 
Congress directed the Centers to implement DOD's comprehensive plans 
for these issues, disseminate best practices, provide guidance, and 
conduct research. The comprehensive plan[Footnote 24] that was issued 
by the DOD/VA Wounded, Ill, and Injured Senior Oversight Committee 
[Footnote 25] combined the two Centers into one and reported that DOD 
had created this Center--DCOE--to lead efforts in PH and TBI practice 
standards, training, outreach, research, and direct care. The 
Committee assigned to DCOE the responsibility for acting as an 
information clearinghouse that would allow any servicemember or family 
member to navigate the system of care "with a single phone call." It 
also assigned DCOE the responsibility for coordinating an overarching 
program of research that is relevant to the needs of the field, in 
coordination with other DOD organizations, the Department of Veterans 
Affairs, the National Institutes of Health, and other partners. In its 
own plan, DCOE further defined its anticipated mission. DCOE said that 
it would serve as a coordinating authority for DOD's PH and TBI issues 
and perform a DOD-wide gap analysis to identify needed programming. 
DCOE said that it would also provide teams for site visits to evaluate 
facilities and innovative practices and coordinate initiatives to 
address research gaps. 

Multiple Organizations Have Purview over PH and TBI Initiatives: 

As stated previously, DCOE, in defining its mission, reported that it 
would serve as DOD's coordinating authority on PH and TBI matters. 
However, as also stated earlier, we found, as we had in our previous 
2011 reports, that DCOE's strategic plan did not reflect a clear 
mission that focused the organization on its statutory 
responsibilities. Instead, responsibilities are dispersed among the 
TRICARE Management Activity, the Army Medical Research and Materiel 
Command, and others. While the Office of the Assistant Secretary of 
Defense for Health Affairs has broad oversight for all of DOD's 
missions, including DCOE, its global role prevents it from focusing on 
PH and TBI activities specifically.[Footnote 26] At present, to report 
on DOD Defense Health Program-funded PH and TBI activities, the Office 
of the Assistant Secretary of Defense for Health Affairs must collect 
information on activities funded with O&M and procurement funds from 
the TRICARE Management Activity, while for activities funded with 
RDT&E funds, it collects the information from the Army Medical 
Research and Materiel Command and other DOD research activities. It 
must additionally obtain information directly from the military 
services, which have been given funds for these purposes. More 
importantly, no single organization is devoted to ensuring that 
accurate and timely data are available on DOD's PH and TBI activities, 
which would help to ensure that DOD-wide efforts are coordinated and 
do not involve duplication of effort. 

Within the Office of the Assistant Secretary of Defense for Health 
Affairs, the TRICARE Management Activity Program, Budget, and 
Execution Division manages O&M and procurement funds for PH and TBI. 
The Office of the Chief Financial Officer is responsible for an 
internal, Web-based information system used to record and track 
Defense Health Program-related data on O&M-funded PH and TBI 
initiatives. The Office of Force Health Protection and Readiness 
operates and maintains a data management system called ProSight, which 
contains descriptions of the O&M-funded projects. 

Separately, the Army Medical Research and Materiel Command manages the 
majority of the Defense Health Program's RDT&E funds for PH and TBI. 
In 2006, Congress directed the Secretary of Defense to designate an 
executive agent for coordinating and managing DOD's medical research 
efforts and programs relating to the prevention, mitigation, and 
treatment of blast injuries.[Footnote 27] In response, DOD issued a 
directive in July 2006 designating the Secretary of the Army as the 
executive agent[Footnote 28] for the purpose specified by Congress. 
The Secretary of the Army delegated the authority and assigned 
executive responsibility to the Assistant Secretary of the Army 
(Acquisition, Logistics, and Technology), who delegated authority and 
assigned program responsibility to the U.S. Army Medical Command. The 
Blast Injury Coordinating Office was established within and is managed 
by the Medical Research and Materiel Command, a subcomponent of the 
Army Medical Command, to assist in coordinating and managing relevant 
DOD medical research efforts and programs related to the prevention, 
mitigation, and treatment of blast injuries. According to the 
directive, a blast injury is defined as an injury that occurs as a 
result of the detonation of high explosives, including vehicle-borne 
and person-borne explosive devices, rocket-propelled grenades, and 
improvised explosive devices. According to a Medical Research and 
Materiel Command official, medical research on blast injuries is very 
often applicable to the prevention, mitigation, and treatment of PTSD, 
PH, and TBI. 

To identify DOD's PH and TBI funding and projects, the Office of the 
Assistant Secretary of Defense for Health Affairs must reach out to 
several entities, acquire the discrete sets of data needed, and 
assemble them into a single integrated list. In conducting our review, 
we, too, had to obtain the information from several different sources, 
including the TRICARE Management Activity, the Medical Research and 
Materiel Command, and the individual military services, in order to 
compile a comprehensive, up-to-date, and reliable list of its PH and 
TBI activities. The office that provided us with data on obligations 
and expenditures related to O&M-funded PH and TBI was the TRICARE 
Management Activity Office of the Chief Financial Officer. The office 
that provided us descriptions of O&M-funded PH and TBI projects was 
the Assistant Secretary of Defense for Health Affairs' Force Health 
Protection and Readiness office. Officials in this office, which 
maintains the ProSight database, told us this database is solely a 
tool for monitoring the quantity and type of projects--emphasizing 
that it is not an authoritative source of information on associated 
obligations or expenditures. In light of this limitation, as well as 
our assessment that the reported O&M obligation data TRICARE 
Management Activity provided us were unreliable, we requested 
obligation information on DOD's O&M-and procurement-related PH and TBI 
projects directly from the military services, as discussed above. To 
obtain information on RDT&E projects, we requested data from the Army 
Medical Research and Materiel Command, which has visibility over the 
majority of Defense Health Program RDT&E appropriations. In a recently 
issued report, the RAND Corporation similarly found the identification 
of PH and TBI programs to be "a complex task." RAND also found that no 
single source in DOD or any of the branches of service maintains a 
complete listing of programs, tracks the development of new programs, 
or has appropriate resources in place to direct servicemembers and 
their families to the full array of programs that best meet their 
needs.[Footnote 29] 

Other Entities Also Play Roles in PH and TBI Matters: 

By the time DCOE was established in 2007, review groups, task forces, 
and presidential commissions had already developed more than 400 
recommendations on how to improve the care and treatment of wounded 
warriors. These groups agreed that the Military Health System lacked 
the fiscal resources and fully trained personnel needed to fulfill its 
mission to support PH and TBI in peacetime, as well as the enhanced 
requirements imposed during times of conflict. 

For example, to address rising concerns over the care and treatment of 
wounded warriors from Operations Enduring Freedom and Iraqi Freedom, 
in May 2007 the Secretaries of Defense and Veterans Affairs created a 
Senior Oversight Committee composed of officials and service chiefs 
from DOD, the Department of Veterans Affairs, and the military 
services. Tasked with initiating the process of reforming the system 
of care for wounded warriors, the committee dedicated one of its eight 
lines of action to addressing the issues of PH and TBI. In June 2007, 
the Office of Force Health Protection and Readiness, in the Office of 
the Assistant Secretary of Defense for Health Affairs, brought in 
subject matter experts from each of the services and the Department of 
Veterans Affairs' healthcare system to establish the "Red Cell"--a 
group meant to cut across routine channels to quickly implement 
changes. The Red Cell was tasked with reviewing the 400 
recommendations for improving the care and treatment of wounded 
warriors and with formulating an action plan, developing proposals for 
policy changes needed to implement the plan, and serving as liaison 
with DOD and the Department of Veterans Affairs. DOD officials told us 
that the Committee remains in existence, although it was originally 
intended to be temporary. Section 1624 of the National Defense 
Authorization Act for Fiscal Year 2008 required that a report be 
submitted to Congress on the establishment of the centers of 
excellence for PH and TBI, among other things, and the Committee 
addressed that requirement.[Footnote 30] Section 1618 of the 2008 
National Defense Authorization Act also required that the Secretary of 
Defense, in consultation with the Secretary of Veterans Affairs, 
submit a comprehensive plan for programs and activities of the 
Department of Defense to prevent, diagnose, mitigate, treat, research, 
and otherwise respond to traumatic brain injury, PTSD, and other 
mental health conditions in members of the armed forces. A report was 
issued in response to that requirement in October 2008.[Footnote 31] 

When the Senior Oversight Committee was established in 2007, other 
committees already existed whose responsibilities included oversight 
of activities for PH and TBI. For example, in 2003 Congress 
established the Department of Defense-Department of Veterans Affairs 
Joint Executive Committee, to comprise the Deputy Secretary of 
Veterans Affairs and DOD's Under Secretary of Defense for Personnel 
and Readiness, as well as others designated by the Secretary of 
Veterans Affairs and the Secretary of Defense.[Footnote 32] This 
committee was tasked, among other things, with reviewing and making 
recommendations for existing policies, procedures, and practices 
relating to the coordination and sharing of resources between DOD and 
the Department of Veterans Affairs and with identifying changes that 
would promote mutually beneficial coordination, use, or exchange of 
services and resources of the two Departments. Additionally, the law 
requires the committee to submit an annual report to the Secretaries, 
recommending strategic direction for joint coordination and sharing 
efforts between and within the two Departments, under 38 U.S.C.§ 8111, 
and to oversee implementation of those efforts. The Joint Executive 
Committee subsequently issued a Joint Strategic Plan for 2010-2012 to 
provide direction on DOD's and the Department of Veterans Affairs' 
joint efforts to coordinate and share resources. Under Goal 2, High 
Quality Health Care, this plan included various initiatives involving 
PH, TBI, and the Centers of Excellence. The Committee also created a 
subgroup to oversee these issues: the Health Executive Council's 
Psychological Health/Traumatic Brain Injury Working Group. 

In 2002, a committee was established by DOD to provide guidance and 
oversight of all military health system programs: the Senior Military 
Medical Advisory Council, chaired by the Assistant Secretary of 
Defense for Health Affairs and made up of the services' surgeons 
general. The task of this council is to make recommendations 
concerning the military health system. In 2011, one of this council's 
initiatives was to create a Center of Excellence Advisory Board, which 
will have responsibility for reviewing all centers of excellence, 
including DCOE, with a view toward eliminating any duplication of 
efforts or unnecessary services. 

As early as 1980, DOD had also established a committee to coordinate 
the efforts undertaken by the offices of the Under Secretary of 
Defense for Acquisition, Technology, and Logistics and the Assistant 
Secretary of Defense for Health Affairs. In that year, DOD created the 
Armed Services Biomedical Research Evaluation and Management Committee 
to be co-chaired by the Director of Defense Research and Engineering 
under the Under Secretary of Defense for Acquisition, Technology, and 
Logistics and the Assistant Secretary of Defense for Health Affairs. 
The purpose of this committee was to facilitate coordination within 
DOD biomedical research and development. (See table 1 for a listing of 
the organizations that play roles in addressing PH and TBI matters.) 

Table 1: Defense Components with Roles Addressing PH and TBI: 

Number: 1; 
Defense component: Office of the Assistant Secretary of Defense for 
Health Affairs; 
Duties: Oversees the Military Health System, a global medical network 
that provides health care to all U.S. military personnel worldwide. 

Number: 1; 
Defense component: TRICARE Management Activity; 
Duties: Manages and executes O&M and procurement funding for PH and 
TBI, including funding for the Defense Center of Excellence. 

Number: 1; 
Defense component: Office of Force Health Protection and Readiness; 
Duties: Coordinates and transmits the annual report required by 
section 1634 of the National Defense Authorization Act for Fiscal Year 
2008 to Congress on behalf of DOD and works in conjunction with the 
Office of the Chief Financial Officer, TRICARE Management Activity, to 
obtain the requested amounts; Operates and maintains a data management 
system called ProSight, which contains descriptions of the O&M-funded 
projects. 

Number: 1; 
Defense component: Defense Center of Excellence for PH and TBI; 
Duties: Established in 2007 to lead DOD's effort to develop excellence 
in its prevention of, outreach to, and care for those suffering from 
these conditions. 

Number: 2; 
Defense component: Army Medical Research and Materiel Command; 
Duties: Manages and executes the majority of Defense Health Program 
RDT&E funding for PH and TBI. 

Number: 3; 
Defense component: Joint DOD/Veterans Affairs Wounded, Ill, and 
Injured Senior Oversight Committee; 
Duties: Established in 2007 and tasked with initiating reform of the 
system of care for wounded warriors; one of its eight lines of action 
addresses the issues of PH and TBI. 

Number: 4; 
Defense component: Joint Executive Committee; 
(Undersecretary of Defense for Personnel and Readiness and Deputy 
Secretary for Veterans Affairs); 
Duties: Established in 2003 and tasked with reviewing and making 
recommendations regarding policies, procedures, and practices relating 
to the coordination and sharing of resources between DOD and the 
Department of Veterans Affairs. 

Number: 4; 
Defense component: Health Executive Council's Psychological 
Health/Traumatic Brain Injury Working Group; 
Duties: Subgroup created by the Joint Executive Committee to oversee 
PH and TBI issues. 

Number: 5; 
Defense component: Senior Military Medical Advisory Council; 
Duties: Established in 2002 and tasked with making recommendations 
concerning the military health system; 
recently created the Center of Excellence Advisory Board. 

Number: 5; 
Defense component: Center of Excellence Advisory Board; 
Duties: Established in 2011 and tasked with reviewing all centers of 
excellence, including DCOE, so as to avert any duplication of efforts 
or unnecessary services. 

Number: 6; 
Defense component: Armed Services Biomedical Research Evaluation and 
Management Committee; 
Duties: Established in 1980 and tasked with facilitating coordination 
within DOD for biomedical research and development. 

Source: Compiled by GAO based on DOD information. 

[End of table] 

While these DOD and Veterans Affairs' organizations may each serve a 
unique purpose, the organization responsible for addressing reform 
efforts needed for PH and TBI (the DOD/VA Wounded, Ill, and Injured 
Senior Oversight Committee) intended DCOE to be the information 
clearinghouse and coordinator of an overarching program of research 
for PH and TBI matters. DCOE did not ultimately grow into that role. 
Also, though the Office of the Assistant Secretary of Defense for 
Health Affairs provides broad oversight for all of DOD's missions, its 
global role prevents it from focusing on PH and TBI activities 
specifically. Until a single organization is tasked with coordinating 
DOD's PH and TBI activities, DOD's ability to manage these activities 
will remain fragmented, and duplication of effort remains a 
possibility. 

Conclusions: 

Despite the heightened significance of PH and TBI matters, the 
attention drawn to them by numerous studies, and the more than $2.7 
billion of appropriated funds that supported related programs, DOD is 
not currently in a position to readily report in a reliable manner on 
how funds are being used to provide benefits to servicemembers. While 
DOD has undertaken a number of initiatives, the information that it 
has been reporting has been incomplete and based on data that are 
unreliable. Further, DOD's visibility of PH and TBI activities remains 
limited because it must collect information from many entities--the 
TRICARE Management Activity, the Assistant Secretary of Defense for 
Health Affairs' Force Health Protection and Readiness Office, the Army 
Medical Research and Materiel Command, and the individual military 
services. At present, there is no entity tasked with maintaining up-to-
date and comprehensive information on DOD's PH and TBI activities and, 
more importantly, no entity coordinates DOD's PH and TBI activities. 
As a result, DOD is hampered in its efforts to ensure that resources 
are used effectively to meet goals; and Congress and entities with 
oversight responsibility will be limited in their ability to obtain 
reliable information to guide their decisionmaking. 

Recommendations for Executive Action: 

To increase visibility over how DOD is spending appropriated funds to 
address PH and TBI conditions, we recommend that the Secretary of 
Defense direct the Assistant Secretary of Defense for Health Affairs 
to take the following four actions: 

(1) include expenditures for PH and TBI activities in annual reports 
to Congress as directed by Section 1634 of the National Defense 
Authorization Act for Fiscal Year 2008; 

(2) develop, maintain, and coordinate quality control mechanisms that 
help ensure that the obligation and expenditure data they report on PH 
and TBI projects and research are complete and accurate; 

(3) if patient costs are provided in future annual reports, clearly 
show what is included and not included for all patient costs; and: 

(4) revisit DCOE's role as DOD's coordinating authority for issues 
concerning PH and TBI, as stated in its own plan, and determine 
whether it or another organization should perform this function. 

Agency Comments and Our Evaluation: 

In written comments on a draft of this report, DOD concurred with all 
four of our recommendations (see appendix V). In concurring with our 
first recommendation, which addresses the need to include expenditures 
in DOD's annual reports, DOD stated that it will include available 
expenditure data in the next annual report but noted that expenditure 
data often lag behind the end of the fiscal year by several months. We 
agree, but since the upcoming annual report is the fifth report, 
expenditure data would be available for the preceding years. 

In commenting on our second recommendation, which concerns quality 
control mechanisms to help ensure the completeness and accuracy of 
data, DOD stated that the DOD accounting structure does not allow for 
a single system of assembling and reporting fiscal data but that the 
Office of the Assistant Secretary of Defense for Health Affairs and 
TRICARE Management Activity will take steps to improve the accuracy 
and reliability of the data. While we commend DOD's efforts to improve 
the accuracy of its data, we did not recommend that it maintain a 
single data system; we believe that multiple systems can be 
coordinated to provide accurate and reliable data if appropriate 
internal controls are in place. 

In concurring with our third recommendation--to clearly show in annual 
reports what is included and what is not included in the calculation 
of patient costs, if such costs are to be provided in future annual 
reports--DOD stated it will omit this information in future reports, 
as it is confusing. While DOD's report is not explicitly required to 
include the cost of patient care, we believe that DOD's inclusion of 
the cost of patient care in its annual reports, if clearly presented, 
would provide a more complete picture of overall TBI and PH costs. 

Lastly, in concurring with our fourth recommendation, to revisit 
DCOE's role as DOD's coordinating authority for issues concerning PH 
and TBI and determine whether DCOE or another organization should 
perform this function, DOD stated that a "revisit" of DCOE's role is 
currently underway. DOD stated that the Center of Excellence Advisory 
Board, part of the Military Health System's governance structure, is 
overseeing the development of a revised and detailed concept of 
operations for DCOE. DOD also stated that its Cost Assessment and 
Program Evaluation Office has requested that DCOE assume a larger role 
in the evaluation of psychological health and traumatic brain injury 
programs. We commend DOD for undertaking a revisit of DCOE's role, 
especially in having DCOE evaluate current programs. Such evaluations 
should provide DOD with valuable information that will help 
decisionmakers determine how to maximize resources to ensure that 
funds are spent as efficiently as possible. 

The Office of the Assistant Secretary of Defense for Health Affairs 
and the Department of the Army provided technical comments as well, 
which we have addressed in the report text, where applicable. 

We are sending copies of this report to the Secretary of Defense, the 
Assistant Secretary of Defense for Health Affairs, appropriate 
congressional committees, and other interested parties. This report 
will also be available at no charge on GAO's Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have questions about this report, please contact 
me at (202) 512-3604 or farrellb@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. Key contributors to this report are 
listed in appendix VI. 

Signed by: 

Brenda S. Farrell: 
Director, Defense Capabilities and Management: 

[End of section] 

Appendix I: Scope and Methodology: 

In the course of our review, we obtained information from or 
interviewed officials with the Office of the Secretary of Defense, in 
Falls Church, Virginia; TRICARE Management Activity, in Falls Church, 
Virginia; Army Medical Command, in Joint Base San Antonio, Texas; Army 
Medical Research and Materiel Command, in Fort Detrick, Maryland; Navy 
Bureau of Medicine, in Washington, D.C.; and Air Force Medical 
Service, in Joint Base San Antonio, Texas. 

To determine how much funding was received by activities related to PH 
and TBI for fiscal years 2007 through 2010, we reviewed DOD 
appropriations acts and accompanying committee reports from fiscal 
years 2007 through 2010, and we interviewed and obtained documentation 
from officials with the TRICARE Management Activity. To assess how 
accurately DOD has been in reporting obligations and expenditures for 
PH and TBI in its required annual reports to Congress, we reviewed 
section 1634 of the 2008 National Defense Authorization Act mandating 
the annual reports and analyzed DOD’s annual reports to Congress on 
expenditures for activities on PH and TBI for calendar years 2008, 
2009, and 2010. In addition, we interviewed officials with the Office 
of the Assistant Secretary of Defense for Health Affairs and the 
TRICARE Management Activity regarding the methodology used to develop 
each of the four annual reports. To determine the PH and TBI 
activities for which O&M and procurement funds had been obligated, we 
obtained documentation from and conducted interviews with officials at 
the TRICARE Management Activity. To determine activities for which 
RDT&E funds had been obligated, we obtained documentation from and 
conducted interviews with officials from the Army Medical Research and 
Materiel Command. To assess and verify the reliability of the 
obligation data received from these DOD entities, we drafted and 
distributed a data reliability assessment questionnaire to DOD 
entities that provided us financial and project information. From the 
officials’ responses, we received information on the purpose of, the 
collection processes, and the internal quality controls used by the 
respective entity’s financial information system. In addition, we 
interviewed officials with the TRICARE Management Activity and the 
military departments about their policies and internal control 
procedures used to ensure the accuracy and reliability of information 
entered into DOD’s information and financial management systems. We 
and the DOD Inspector General have reported on the unreliability of 
DOD’s financial transactions data, including accounting for 
obligations.[Footnote 33] However, because these data are the only 
data available describing how PH/TBI funds are used and they are the 
data used by DOD and the military services to manage their operations, 
we determined that it is appropriate to use these data for the purpose 
of our report. Although we requested and received expenditure data 
from DOD, we identified several inconsistencies and determined the 
data were unreliable. As a result, we excluded that information and 
reported only on those PH and TBI activities for which funds had been 
obligated. 

To evaluate DOD's ability to coordinate all PH and TBI activities to 
help ensure that funds are used to support programs of the most 
benefit to servicemembers, we interviewed officials with the Office of 
the Assistant Secretary of Defense for Health Affairs, TRICARE 
Management Activity, Defense Center of Excellence for Psychological 
Health and Traumatic Brain Injury, and Army Medical Research and 
Materiel Command. 

In addition, we reviewed the legislation establishing the Defense 
Centers of Excellence. We also reviewed the Senior Oversight 
Committee's 2008 report to Congress outlining its strategy for 
transforming and expanding PH and TBI services and providing 
protection, prevention, diagnosis, treatment, recovery, and care 
transition to military members. We also reviewed section 583 of the 
National Defense Authorization Act for 2004 that established the Joint 
Executive Committee, which was tasked with, among other things, 
reviewing policies, procedures, and practices relating to the 
coordination and sharing of resources between the Department of 
Veterans Affairs and DOD and making related recommendations. We 
reviewed the Joint Executive Council's Joint Strategic Plan for 2010-
2012, which provided direction on DOD's and the Department of Veterans 
Affairs' joint efforts to coordinate and share resources and described 
a subgroup formed to oversee PH and TBI issues, the Health Executive 
Council's Psychological Health/Traumatic Brain Injury Working Group. 
In addition, we reviewed documents describing the role of a committee 
established by DOD in 2002 to provide guidance and oversight of all 
military health system programs: the Senior Military Medical Advisory 
Committee, chaired by the Assistant Secretary of Defense for Health 
Affairs and made up of the services' surgeons general. Finally, we 
reviewed DOD's guidance on the Armed Services Biomedical Research 
Evaluation and Management Committee to coordinate efforts undertaken 
by the offices of the Under Secretary of Defense for Acquisition, 
Technology and Logistics and the Assistant Secretary of Defense for 
Health Affairs. 

We conducted this performance audit from July 2010 through January 
2012 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Responsibilities for the Defense Centers of Excellence as 
Detailed in the National Defense Authorization Act for Fiscal Year 
2008: 

In sections 1621 and 1622 of the National Defense Authorization Act 
for Fiscal Year 2008, Pub. L. No. 110-181 (2008), Congress directed 
the Department of Defense to establish Defense Centers of Excellence 
for Traumatic Brain Injury (TBI) and for Post-Traumatic Stress 
Disorder (PTSD) and other mental health conditions. 

Section 1621 states that the Center of Excellence for TBI shall have 
the following responsibilities: 

1. To implement the comprehensive plan and strategy for the Department 
of Defense, required by section 1618 of this Act, for the prevention, 
diagnosis, mitigation, treatment, and rehabilitation of traumatic 
brain injury, including research on gender and ethnic group-specific 
health needs related to traumatic brain injury. 

2. To provide for the development, testing, and dissemination within 
the Department of best practices for the treatment of traumatic brain 
injury. 

3. To provide guidance for the mental health system of the Department 
in determining the mental health and neurological health personnel 
required to provide quality mental health care for members of the 
Armed Forces with traumatic brain injury. 

4. To establish, implement, and oversee a comprehensive program to 
train mental health and neurological health professionals of the 
Department in the treatment of traumatic brain injury. 

5. To facilitate advancements in the study of the short-term and long-
term psychological effects of traumatic brain injury. 

6. To disseminate within the military medical treatment facilities of 
the Department best practices for training mental health 
professionals, including neurological health professionals, with 
respect to traumatic brain injury. 

7. To conduct basic science and translational research on traumatic 
brain injury for the purposes of understanding the etiology of 
traumatic brain injury and developing preventive interventions and new 
treatments. 

8. To develop programs and outreach strategies for families of members 
of the Armed Forces with traumatic brain injury in order to mitigate 
the negative impacts of traumatic brain injury on such family members 
and to support the recovery of such members from traumatic brain 
injury. 

9. To conduct research on the mental health needs of families of 
members of the Armed Forces with traumatic brain injury and develop 
protocols to address any needs identified through such research. 

10. To conduct longitudinal studies (using imaging technology and 
other proven research methods) on members of the Armed Forces with 
traumatic brain injury to identify early signs of Alzheimer's disease, 
Parkinson's disease, or other manifestations of neurodegeneration, as 
well as epilepsy, in such members, in coordination with the studies 
authorized by section 721 of the John Warner National Defense 
Authorization Act for Fiscal Year 2007 (Public Law 109-364; 120 Stat. 
2294) and other studies of the Department of Defense and the 
Department of Veterans Affairs that address the connection between 
exposure to combat and the development of Alzheimer's disease, 
Parkinson's disease, and other neurodegenerative disorders, as well as 
epilepsy. 

11. To develop and oversee a long-term plan to increase the number of 
mental health and neurological health professionals within the 
Department in order to facilitate the meeting by the Department of the 
needs of members of the Armed Forces with traumatic brain injury until 
their transition to care and treatment from the Department of Veterans 
Affairs. 

12. To develop a program on comprehensive pain management, including 
management of acute and chronic pain, to utilize current and develop 
new treatments for pain, and to identify and disseminate best 
practices on pain management related to traumatic brain injury. 

13. Such other responsibilities as the Secretary shall specify. 

Section 1622 states that the Center of Excellence for PTSD and Other 
Mental Health Conditions shall have the following responsibilities: 

1. To implement the comprehensive plan and strategy for the Department 
of Defense, required by section 1618 of this Act, for the prevention, 
diagnosis, mitigation, treatment, and rehabilitation of post-traumatic 
stress disorder and other mental health conditions, including research 
on gender and ethnic group-specific health needs related to post-
traumatic stress disorder and other mental health conditions. 

2. To provide for the development, testing, and dissemination within 
the Department of best practices for the treatment of post-traumatic 
stress disorder and other mental health conditions. 

3. To provide guidance for the mental health system of the Department 
in determining the mental health and neurological health personnel 
required to provide quality mental health care for members of the 
Armed Forces with post-traumatic stress disorder and other mental 
health conditions. 

4. To establish, implement, and oversee a comprehensive program to 
train mental health and neurological health professionals of the 
Department in the treatment of post-traumatic stress disorder and 
other mental health conditions. 

5. To facilitate advancements in the study of the short-term and long-
term psychological effects of post-traumatic stress disorder and other 
mental health conditions. 

6. To disseminate within the military medical treatment facilities of 
the Department best practices for training mental health 
professionals, including neurological health professionals, with 
respect to post-traumatic stress disorder and other mental health 
conditions. 

7. To conduct basic science and translational research on post-
traumatic stress disorder and other mental health conditions for the 
purposes of understanding the etiology of post-traumatic stress 
disorder, and developing preventive interventions and new treatments. 

8. To develop programs and outreach strategies for families of members 
of the Armed Forces with post-traumatic stress disorder and other 
mental health conditions in order to mitigate the negative impacts of 
post-traumatic stress disorder and other mental health conditions on 
such family members and to support the recovery of such members from 
post-traumatic stress disorder and other mental health conditions. 

9. To conduct research on the mental health needs of families of 
members of the Armed Forces with post-traumatic stress disorder and 
other mental health conditions and develop protocols to address any 
needs identified through such research. 

10. To develop and oversee a long-term plan to increase the number of 
mental health and neurological health professionals within the 
Department in order to facilitate the meeting by the Department of the 
needs of members of the Armed Forces with post-traumatic stress 
disorder and other mental health conditions until their transition to 
care and treatment from the Department of Veterans Affairs. 

[End of section] 

Appendix III: RDT&E-Funded Projects: 

The Army Medical Research and Materiel Command, which has visibility 
over RDT&E-funded work for PH and TBI, identified 397 projects that 
were underway during fiscal years 2007 through 2009; data for all of 
fiscal year 2010 were unavailable at the time of our data request. 
Sixty-six percent of the 397 projects were Research and Technology 
Development (nonclinical) projects. These types of studies form the 
knowledge-and technology-based foundation necessary to establish the 
initial feasibility and practicality of proposed solutions to 
problems. The remaining 34 percent of the 397 projects were Clinical 
Research and Development--projects that are typically conducted in a 
clinical setting using human research volunteers (including patients) 
and are directed at amassing the definitive level of evidence required 
to inform changes in medical practice or required for licensure of a 
product regulated by the Food and Drug Administration. Although there 
were twice as many nonclinical as there were clinical projects, 
dollars awarded were distributed fairly evenly between these two types. 

Table 2: RDT&E-funded Projects Addressing PH and TBI: 

A Comprehensive Approach in Dissemination of Evidence-Based Care for 
Post-Traumatic Stress Disorder (PTSD); 
Number of projects funded under title: 1. 

A Double Blind Trial of Divalproex Sodium for Affective Liability and 
Alcohol Use Following Traumatic Brain Injury (TBI); 
Number of projects funded under title: 1. 

A Placebo-Controlled Augmentation Trial of Prazosin for Combat Trauma 
PTSD; 
Number of projects funded under title: 1. 

A Randomized Clinical Trial of Ganaxolone for the Treatment of Severe 
Traumatic Brain Injury; 
Number of projects funded under title: 2. 

A Randomized Controlled Study of Mind-Body Skills Groups for Treatment 
of War-Zone Stress in Military and Veteran Populations; 
Number of projects funded under title: 1. 

A Randomized Controlled Trial of Medical Therapies for Chronic Post-
Traumatic Headaches; 
Number of projects funded under title: 1. 

A Randomized Effectiveness Trial of a Systems-Level Approach to 
Stepped Care for War-Related PTSD; 
Number of projects funded under title: 3. 

A Randomized, Placebo-Controlled Trial of the Dopamine Beta 
Hydroxylase (DBH) Inhibitor, Nepicastat, for the Treatment of PTSD in 
Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) 
Veterans; 
Number of projects funded under title: 1. 

A Randomized, Placebo-Controlled Trial of the Dopamine-?-Hydroxylase 
(DBH) Inhibitor, Nepicastat for the Treatment of PTSD in OIF/OEF 
Veterans; 
Number of projects funded under title: 1. 

Acupuncture as a Novel Technique for Treating Insomnia in the 
Outpatient Traumatic Brain Injury Population: A Randomized Controlled 
Trial; 
Number of projects funded under title: 1. 

Acupuncture for Combat-Related Post-Traumatic Stress Disorder; 
Number of projects funded under title: . 

Acupuncture for the Treatment of Trauma-Induced Spectrum Disorder: A 
Three-Armed Randomized Pilot Study; 
Number of projects funded under title: 1. 

Adaptive Disclosure: A Combat-Specific PTSD Treatment; 
Number of projects funded under title: 3. 

Addressing the Needs of Children and Families of Combat Injured; 
Number of projects funded under title: 1. 

Advanced Restoration Therapies in Spinal Cord Injury; 
Number of projects funded under title: 2. 

An Evaluation of Cognitive Processing Therapy to Treat Veterans in a 
PTSD Residential Rehabilitation Program; 
Number of projects funded under title: 1. 

Biomarker Assessment for Neurotrauma Diagnosis and Improved Triage 
System (BANDITS) with Modification-assessment of biomarkers of 
concussion and acute TBI; 
Number of projects funded under title: 2. 

Biomarkers for PTSD; 
Number of projects funded under title: 1. 

Building Infrastructure to Accelerate Transfer of Basic Research in 
Spinal Cord Injury (SCI) to Clinical Practice: North American Clinical 
Trials Network (NACTN) for Treatment of Spinal Cord Injury; 
Number of projects funded under title: 1. 

Building Neurocognitive Resilience with Attention Training in a 
Military Cohort; 
Number of projects funded under title: 1. 

Burr Hole Creation Simulation-Based Training System; 
Number of projects funded under title: 1. 

Cognitive Behavioral Therapy (CBT) for TRICARE Management Activities 
in OEF/OIF Veterans; 
Number of projects funded under title: 1. 

Clinical Phase II B Trial of Oxycyte Perfluorocarbon in Severe Human 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Clinical Phase II-B Trial of Oxycyte Perfluorocarbon in Severe Human 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Cognitive Behavioral Social Rhythm Therapy (CBSRT) for Sleep and Mood 
Disturbances in Veterans with PTSD; 
Number of projects funded under title: 1. 

Combat Stress Casualty Reduction: Predeployment Stress Inoculation 
Training; 
Number of projects funded under title: 1. 

Combat, Sexual Assault, and Post-Traumatic Stress in OIF/OEF Military 
Women; 
Number of projects funded under title: 1. 

Comparing Internet and In-Person Brief Cognitive Behavioral Therapy of 
Insomnia; 
Number of projects funded under title: 1. 

Comparing Virtual Reality Exposure Therapy to Prolonged Exposure in 
the Treatment of Soldiers with PTSD; 
Number of projects funded under title: 1. 

Computer-Guided Prolonged Exposure Therapy for PTSD; 
Number of projects funded under title: 1. 

Day-to-Day Mindfulness Skills for Improving Veterans' Quality of Life 
and Wellness in Health Care Mental Health Settings; 
Number of projects funded under title: 1. 

Development and Pilot of an Intervention for Military Personnel and 
Their Families; 
Number of projects funded under title: 1. 

Development and Validation of a PTSD-Related Impairment Scale; 
Number of projects funded under title: 1. 

Discovery and Validation of Peripheral Biomarkers of Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Dissemination of Evidence-Based CBT Intervention Components: Online 
Self-Administered Training for Providers Treating Military Deployment-
Related PTSD; 
Number of projects funded under title: 2. 

Does Integrating Primary Care and Mental Health Services Improve 
Mental Health Services Utilization, Symptoms, and Functioning Among 
OEF/OIF Veterans?; 
Number of projects funded under title: 1. 

Effectiveness of Cognitive Exposure and Skills Group Manualized 
Treatments in OIF/OEF Female Veterans; 
Number of projects funded under title: 2. 

Enhancing Emotion Regulation during Driving in OEF/OIF Veterans; 
Number of projects funded under title: 1. 

Enhancing Exposure Therapy for PTSD: Virtual Reality and Imaginal 
Exposure with Cognitive Enhancer; 
Number of projects funded under title: 1. 

Evaluating PTSD on Reproductive Outcomes: Women Deployed in Iraq and 
Afghanistan; 
Number of projects funded under title: 1. 

Evaluation and Impact of mCare, a Cell Phone Based Bi-Directional 
Messaging System, on the Case Management Care of Traumatic Brain 
Injury Patients Assigned to Community Based Warrior in Transition 
Units; 
Number of projects funded under title: 1. 

Evaluation of a Yoga Intervention for PTSD; 
Number of projects funded under title: 2. 

Evaluation of an Acute Ribonucleic Acid (RNA)-Mediated Therapeutic for 
Visual Dysfunction Associated with Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Evaluation of the Tripler Army Medical Center (TAMC) Integrative Pain 
Management Center (IPMC); 
Number of projects funded under title: 2. 

Evidence Based Multimodal Neurodiagnostic Imaging of Traumatic Brain 
Injury and PTSD at SANIC; 
Number of projects funded under title: 1. 

Evidence-Based Multimodal Neurodiagnostic Imaging of Traumatic Brain 
Injury and Post-Traumatic Stress Disorder at SANIC; 
Number of projects funded under title: 2. 

Family Functioning and Soldier PTSD: Correlates of Treatment 
Engagement and Military Job Satisfaction; 
Number of projects funded under title: 1. 

Family-Based Intervention With Traumatized Service Members and Their 
Young Children; 
Number of projects funded under title: 1. 

Families Overcoming and Coping With Stress -Combat Injured (FOCUS-CI): 
A Preventive Intervention With Children and Families of the Combat 
Injured; 
Number of projects funded under title: 1. 

Fiscal Year 2008 Deployment Related Medical Research Program (DRMRP) 
Clinical Trial: Strengthening Pathways to PTSD Recovery Using Systems-
Level Intervention; 
Number of projects funded under title: 1. 

Homecoming Line: Telephone Support for Veterans; 
Number of projects funded under title: 1. 

Hyperbaric Oxygen Therapy in the Treatment of Chronic Mild-Moderate 
Blast-Induced Traumatic Brain Injury Post-Concussion Syndrome (PCS) 
and Post-Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Identification of and At-Risk Interventions for Predeployment 
Psychophysiologic Predictors of Postdeployment Mental Health Outcomes; 
Number of projects funded under title: 1. 

Importance of Virtual Reality in the Treatment of PTSD: Comparison of 
Virtual Reality to a Controlled Stimulus; 
Number of projects funded under title: 1. 

Improving PTSD Outcomes in OIF/OEF Returnees: A Randomized Clinical 
Trial of Hydrocortisone Augmentation of Prolonged Exposure Therapy; 
Number of projects funded under title: 1. 

Initial Randomized Controlled Trial of Acceptance and Commitment 
Therapy (ACT) for Distress and Impairment in OEF/OIF Veterans; 
Number of projects funded under title: 2. 

Innovative Service Delivery for Secondary Prevention of PTSD in At-
Risk OIF-OEF Service Men and Women; 
Number of projects funded under title: 1. 

Integrating Mental Health and Primary Care Services for OEF/OIF Combat 
Veterans With PTSD and Comorbid Disorders: Assessing the Evidence; 
Number of projects funded under title: 1. 

Interhemispheric Information Transfer: A New Diagnostic Method for 
Mild Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Military to Civilian: Randomized Controlled Trial (RCT) of an 
intervention to promote post-deployment reintegration; 
Number of projects funded under title: 1. 

Military, Family, and Community Networks Helping with Reintegration; 
Number of projects funded under title: 1. 

Mindfulness and Self-Compassion Meditation for Combat Post-Traumatic 
Stress Disorder: Randomized Controlled Trial and Mechanistic Study; 
Number of projects funded under title: 1. 

Mission Connect Mild TBI Translational Research Consortium; 
Number of projects funded under title: 3. 

Mortuary Affairs Soldiers: Early Intervention and Altering Barriers to 
Care for Traumatic Stress and PTSD; 
Number of projects funded under title: 1. 

Motivating Treatment Seeking and Behavior Change by Untreated Military 
Personnel Abusing Alcohol or Drugs; 
Number of projects funded under title: 1. 

Non-invasive Monitoring of Cerebral Venous Saturation in Patients with 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Objective Methods to Test Visual Dysfunction in the Presence of 
Cognitive Impairment; 
Number of projects funded under title: 1. 

Oculomotor reflexes as a test of visual dysfunctions in cognitively 
impaired observers; 
Number of projects funded under title: 1. 

Operation Brain Trauma Therapy (OBTT); 
Number of projects funded under title: 1. 

Optimizing Delivery of Mindfulness-Based Military Training 
Interventions in Army Infantry Platoons; 
Number of projects funded under title: 1. 

Phase II Clinical Trial of NNZ-2566 in Traumatic Brain Injury; 
Number of projects funded under title: 3. 

Pilot Trial of Inpatient Cognitive Therapy for the Prevention of 
Suicide in Military Personnel With Acute Stress Disorder or 
Posttraumatic Stress Disorder; 
Number of projects funded under title: 1. 

Prazosin for Treatment of Patients With PTSD and Comorbid Alcohol 
Dependence; 
Number of projects funded under title: 1. 

PTSD and Substance Abuse; 
Number of projects funded under title: 1. 

PTSD Biomarker Studies (Army Research Office); 
Number of projects funded under title: 1. 

PTSD, Comorbid Disorders, and Service Utilization in Women Veterans; 
Number of projects funded under title: 1. 

PTSD/TBI Clinical Consortium Coordinating Center; 
Number of projects funded under title: 2. 

Randomized Controlled Equivalence Trial Comparing Videoconference and 
Face-to-Face Delivery of Cognitive Processing Therapy for PTSD; 
Number of projects funded under title: 1. 

Real-Time EEG Monitoring System (R-TEEMS) for Acute Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Reintegration: The Role of Spouse Telephone Battlemind; 
Number of projects funded under title: 2. 

Reintegration: The Role of Spouse Telephone BATTLEMIND and Developing 
a Family/Community BATTLEMIND Curriculum; 
Number of projects funded under title: 2. 

Restoration of Life Role Participation Through Integrated Cognitive 
and Motor Training for Individuals with TBI; 
Number of projects funded under title: 1. 

Seeking Safety Therapy for PTSD, TBI, and Substance Use Disorder; 
Number of projects funded under title: 1. 

Special Warrior Wellness Action Team (SWWAT) Program at Camp LeJeune; 
Number of projects funded under title: 1. 

Strength at Home: Veteran's Program; 
Number of projects funded under title: 1. 

Suicide Research Alliance; 
Number of projects funded under title: 2. 

Systems Biology Efforts in PTSD; 
Number of projects funded under title: 1. 

Telemedicine for Improved Delivery of Psychosocial Treatments for Post-
Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Telemental Health and Cognitive Processing Therapy for Female Combat 
Veterans with Military-Related PTSD; 
Number of projects funded under title: 1. 

Telemental Health and Cognitive Processing Therapy for Rural Combat 
Veterans with PTSD; 
Number of projects funded under title: 2. 

Telerehabilitation for OIF/OEF Returnees with Combat Related Traumatic 
Brain Injury; 
Number of projects funded under title: 1. 

Telerehabilitation for OIF/OEF Returnees with Combat-Related Traumatic 
Brain Injury; 
Number of projects funded under title: 1. 

The Impact of Meditation on Veterans with Post-Traumatic Stress 
Disorder; 
Number of projects funded under title: 1. 

The Impact of Supported Employment Versus Standard Vocational 
Rehabilitation in Veterans With PTSD; 
Number of projects funded under title: 1. 

The STRONG STAR Multidisciplinary PTSD Research Consortium; 
Number of projects funded under title: 9. 

The Use of Psychiatric Service Dogs in the Treatment of Veterans with 
PTSD; 
Number of projects funded under title: 1. 

To Support Institute of Creative Technologies (ICT) contract W911NF-04-
D-0005; 
Number of projects funded under title: 1. 

Treatment of Traumatic Brain Injury Using NNZ-2566: Clinical Trials; 
Number of projects funded under title: 1. 

Using Functional Magnetic Resonance Imaging (fMRI) to Measure Brain 
Response to Exposure-Based Psychotherapy in Individuals with Combat-
Related PTSD; 
Number of projects funded under title: 1. 

Using Propranolol to Block Memory Reconsolidation in Female Veterans 
with PTSD; 
Number of projects funded under title: 1. 

Validation of the Military Acute Concussion Evaluation (MACE) for In-
Theater Evaluation of Combat-Related Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Validation of the Peritraumatic Behavior Questionnaire-Observer Rated 
(PBQ-OR), an Instrument for Embedded Medical Personnel to Assess In-
Theater Risk for PTSD; 
Number of projects funded under title: 1. 

Virtual Reality and Cellular Phones as a Complementary Intervention 
for Veterans with PTSD and Substance Use Disorders; 
Number of projects funded under title: 1. 

Research and Technology Development (award titles): 

A Behavioral Treatment for Traumatic Brain Injury-Associated Visual 
Dysfunction Based on Adult Cortical Plasticity; 
Number of projects funded under title: 1. 

A Blast Model of Traumatic Brain Injury in Swine; 
Number of projects funded under title: 1. 

A Brain-Machine-Brain Interface for Rewiring of Cortical Circuitry 
after Traumatic Brain Injury; 
Number of projects funded under title: 2. 

A Brief Intervention to Reduce Suicide Risk in Military Service 
Members and Veterans; 
Number of projects funded under title: 1. 

A Longitudinal Study of the Impact of Combat Deployments on Military 
Personnel and Their Families; 
Number of projects funded under title: 1. 

A Multifunctional Blood Substitute (MBS) for Field Resuscitation of 
Polytrauma Combat Casualties with Brain Injury and Concomitant 
Hemorrhagic Shock; 
Number of projects funded under title: 1. 

A Novel Application of Ceftriaxone to Enhance Glutamate Transport 
after Traumatic Brain Injury; 
Number of projects funded under title: 1. 

A Pilot Study to Identify Barriers to Treatment in OIF/OEF Veterans 
with PTSD and Low Back Pain in Establishing Transdisciplinary 
Complementary Interventions; 
Number of projects funded under title: 1. 

A randomized control trial of a community mental health intervention 
for military personnel; 
Number of projects funded under title: 3. 

Advanced Magnetic Resonance Imaging (MRI) in Acute Military TBI; 
Number of projects funded under title: 1. 

Advanced MRI in Blast-Related TBI; 
Number of projects funded under title: 1. 

Advanced Sensors for TBI; 
Number of projects funded under title: 2. 

American Institute for Medical and Biological Engineering (AIMBE) - 
Military Collaboration: Bioengineering Challenges of Brain Trauma 
Conference; 
Number of projects funded under title: 1. 

An fMRI Study of TBI Associated with Blast Injury; 
Number of projects funded under title: 1. 

Antidepressants and the Risk of Self-Harm and Unintentional Injury 
Among Younger Veterans; 
Number of projects funded under title: 1. 

Application of Repetitive Transcranial Magnetic Stimulation (rTMS) to 
Reverse the Molecular Epileptogenic Changes Following Post-Traumatic 
Brain Injury; 
Number of projects funded under title: 1. 

Are Blast Brain Injuries Fundamentally Different than Traditional 
Experimental Models of TBI?; 
Number of projects funded under title: 1. 

Assessment of Acute Concussion in a Combat Environment: Concurrent 
Validity, Sensitivity, and Specificity of the Automated 
Neuropsychological Assessment Metrics (ANAM); 
Number of projects funded under title: 2. 

Adenosine Triphosphate (ATP)-Sensitive Potassium Channels for 
Neuroprotection from Blast-Induced TBI; 
Number of projects funded under title: 1. 

Auditory, Vestibular, and Cognitive Effects from Repeated Blast; 
Number of projects funded under title: 1. 

Auditory, Vestibular, and Cognitive Effects Due to Repeated Blast 
Exposure on the Warfighter; 
Number of projects funded under title: 1. 

BANDITS with Modification-assessment of biomarkers of concussion and 
acute TBI; 
Number of projects funded under title: 1. 

Basic Training and Mental Fitness Study: Enhancing Performance and 
Mental Health; 
Number of projects funded under title: 1. 

Bioluminescence Imaging in Traumatic Brain Injury: Implications for 
Pharmacotherapy; 
Number of projects funded under title: 1. 

Biomarkers: Evaluating and Treating Acute and Chronic TBI; 
Number of projects funded under title: 1. 

Blister Packaging Medication to Increase Treatment for Adherence and 
Clinical Response: Impact on Suicide-related Morbidity and Mortality; 
Number of projects funded under title: 1. 

Blockade of Nociceptin Signaling Reduces Biochemical, Structural, and 
Cognitive Deficits After Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Brain Injury Biomarkers and Behavioral Characterization of mild TBI 
(mTBI) in Soldiers Following Repeated, Low-Level Blast Exposure; 
Number of projects funded under title: 2. 

Brain Injury Biomarkers and Therapy; 
Number of projects funded under title: 1. 

Brain Tissue Regeneration After Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Brain Vulnerability to Repeated Blast Overpressure and Polytrauma; 
Number of projects funded under title: 1. 

Battlefield Research Accelerating Virtual Environments for Military 
Individual Neuro Disorders (BRAVEMIND): Advancing the Virtual 
Iraq/Afghanistan PTSD Exposure Therapy System; 
Number of projects funded under title: 1. 

Breacher Injury Survey II: Prevalence of the Bio-Effects of Repeated 
Low-Level Blast Exposure; 
Number of projects funded under title: 2. 

Brief Cognitive Behavioral Therapy for Military Populations; 
Number of projects funded under title: 1. 

Catecholamines in Posttraumatic Stress Disorder; 
Number of projects funded under title: 1. 

Catechol-O-Methyltransferase, Impulsivity, and Substance Abuse 
Treatment; 
Number of projects funded under title: 1. 

Cerebrovascular Injury in Blast Loading; 
Number of projects funded under title: 1. 

Characterizing the Relationship between Blast Exposure and Mild TBI 
with Dynamic Modeling and Testing in a New Mouse Model; 
Number of projects funded under title: 1. 

Child Adjustment to Parental Combat Deployment: Risk and Resilience 
Models; 
Number of projects funded under title: 1. 

Children of Military Fathers with Post Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Combat Exposure, PTSD, and Misconduct: Direct and Indirect Behavioral 
Impacts of War; 
Number of projects funded under title: 1. 

Combat Operational Stress Stigma Reduction Intervention; 
Number of projects funded under title: 1. 

Combat Stress Intervention Program (Year 3); 
Number of projects funded under title: 1. 

Comprehensive 3-D Model of Shock Wave-Brain Interactions in Blast-
Induced Traumatic Brain; 
Number of projects funded under title: 1. 

Computational Modeling of Causal Mechanisms of Blast Wave-Induced 
Traumatic Brain Injury: A Potential Tool for Injury Prevention; 
Number of projects funded under title: 1. 

Conditioned Fear Extinction and Generalization in Post-Traumatic 
Stress Disorder; 
Number of projects funded under title: 1. 

Conference support for W81XWH-05-2-0094 "Physical and Neuropsychiatric 
Trauma Wound Healing and Tissue Prevention"; 
Number of projects funded under title: 1. 

Corticosterone Administration to Promote Fear Memory Forgetting in an 
Animal Model of PTSD; 
Number of projects funded under title: 1. 

Data Modeling Approaches for Biomarkers in Clinical Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Deep Brain Stimulation of Treatment of Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Deployment Family Stress: Child Neglect and Maltreatment in U.S. Army 
Families; 
Number of projects funded under title: 1. 

Deployment, PTSD Symptoms, and Comorbid Mental Health Conditions in 
the Active Force and Reserve Components; 
Number of projects funded under title: 1. 

Deployment-Related Mild Traumatic Brain Injury (mTBI): Incidence, 
Natural History, and Predictors of Recovery in Soldiers Returning from 
OIF/OEF; 
Number of projects funded under title: 1. 

Design of Effective Therapeutic Interventions for Mild TBI/PTSD Using 
Interactive Virtual World Environments; 
Number of projects funded under title: 1. 

Design of Virtual Reality-Based Therapy to Restore the Whole Body 
Coordination Deficits Following Deployment-Acquired Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Developing Memory Reconsolidation Blockers as Novel PTSD Treatments; 
Number of projects funded under title: 1. 

Development of a Novel Lab-on-a-Tube for Multimodal Monitoring in the 
Injured Warrior; 
Number of projects funded under title: 1. 

Development of a PTSD Population Registry; 
Number of projects funded under title: 2. 

Development of a Vision Assistive Device for Veterans with TBI-
Associated Visual Dysfunctions; 
Number of projects funded under title: 1. 

Development of an Intervention for Soldiers and Veterans with Co-
Occurring Traumatic Brain Injury and Substance Abuse Disorders; 
Number of projects funded under title: 1. 

Development of F-18-Labeled Radiotracers for Positron Emission 
Tomography (PET) Imaging of Brain Alpha-1 Noradrenergic Receptors: 
Potential PTSD Vulnerability and/or Diagnostic Biomarkers; 
Number of projects funded under title: 1. 

Differentiating the severity of Mild and Moderate Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Disequilibrium after Traumatic Brain Injury: Vestibular Mechanisms; 
Number of projects funded under title: 1. 

Do Undetected or Untreated Sleep Disorders Predict PTSD Psychotherapy 
Outcomes?; 
Number of projects funded under title: 1. 

Docosahexaenoic Acid (DHA) versus Placebo in a Special Operations Unit 
with a High Rate of Blast Exposures; 
Number of projects funded under title: 1. 

Drug Related Overdoses Among a Military Population; 
Number of projects funded under title: 1. 

Drug-Encapsulated Immunonanoparticles, Neuron-Targeted Delivery System; 
Number of projects funded under title: 1. 

Early Post-Traumatic Seizures in Military Personnel Result in Long-
Term Disability; 
Number of projects funded under title: 1. 

Effect of a Hypocretin/Orexin Antagonist on Neurocognitive Performance; 
Number of projects funded under title: 2. 

Effects of Repeated Traumatic Brain Injuries in a Combat Setting; 
Number of projects funded under title: 1. 

Electrical Stimulation of the Midbrain to Promote Recovery from 
Traumatic Forebrain Injury; 
Number of projects funded under title: 1. 

Enduring Effects of Traumatic Stress on Brain Neuropeptide Y (NPY) and 
Corticotropin-Releasing Factor (CRF) Systems: Molecular and 
Neuropharmacologic Studies; 
Number of projects funded under title: 1. 

Epidemiological Study of Mild Traumatic Brain Injury Sequelae Caused 
by Blast Exposure During Operations Iraqi Freedom and Enduring Freedom; 
Number of projects funded under title: 1. 

Epigenetic Patterns of PTSD: Deoxyribonucleic Acid (DNA) Methylation 
in Serum of OIF/OEF Service Members; 
Number of projects funded under title: 1. 

Epigenetic Patterns of TBI: DNA Methylation in Serum of OIF/OEF 
Service Members; 
Number of projects funded under title: 1. 

Etiology of Sleep Disorders in PTSD: Potential Role of Inflammatory 
Cytokines; 
Number of projects funded under title: 1. 

Evaluation of a New Screening Approach to Identify Soldiers at High 
Risk for Substance Abuse; 
Number of projects funded under title: 1. 

Evaluation of Prospective Biomarkers for TBI in the Presence of 
Hemorrhagic Shock; 
Number of projects funded under title: 1. 

Eye-Tracking Rapid Attention Computation; 
Number of projects funded under title: 2. 

Fabrication and Testing of a Blast Concussion Burst Sensor; 
Number of projects funded under title: 1. 

Fear Conditioning Effects on Sensitivity to Drug Reward; 
Number of projects funded under title: 1. 

Fibrin Matrix-Supported Mesenchymal Stem Cell Treatment for Traumatic 
Brain Injury; 
Number of projects funded under title: 1. 

Genetic Screen for PTSD-Prone Soldiers; 
Number of projects funded under title: 1. 

Glutamate Transmission Enhancement for Treatment of PTSD; 
Number of projects funded under title: 1. 

Glyburide -Novel Prophylaxis and Effective Treatment for Traumatic 
Brain Injury; 
Number of projects funded under title: 1. 

Health Status and Performance of United States Air Force Airmen 
Following Mild Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Helmet Integrated Nanosensors, Signal Processing and Wireless Real 
Time Data Communication for Monitoring Blast Exposure to Battlefield 
Personnel; 
Number of projects funded under title: 1. 

Helmet Mounted Sensor Recorded Blast Data in Combat; 
Number of projects funded under title: 1. 

Helmet Sensor-Transfer Function and Model Development; 
Number of projects funded under title: 1. 

High Resolution Diffusion Tensor Imaging of Cortical-Subcortical White 
Matter Tracts in TBI; 
Number of projects funded under title: 1. 

High Risk Suicidal Behavior in Veterans-Assessment of Predictors and 
Efficacy of Dialectical Behavior Therapy; 
Number of projects funded under title: 1. 

High-Throughput Screening of Therapeutic Neural Stimulation Targets: 
Toward Principles of Preventing and Treating Post-Traumatic Stress 
Disorder; 
Number of projects funded under title: 1. 

Hormonal Regulation of Extinction: Implications for Gender Differences 
in the Mechanisms of PTSD; 
Number of projects funded under title: 1. 

Identification and Validation of Novel Therapeutics Targets for 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Identification of Gene Expression Patterns in Brain Tissues and 
Peripheral White Blood Cells of Rat Model of Post-Traumatic Stress 
Disorder; 
Number of projects funded under title: 1. 

Identifying Biomarkers that Distinguish Post-Traumatic Stress Disorder 
and Mild Traumatic Brain Injury Using Advanced Magnetic Resonance 
Spectroscopy; 
Number of projects funded under title: 2. 

Implantable Microsystems for Anatomical Rewiring of Cortical 
Circuitry: A New Approach for Brain Repair; 
Number of projects funded under title: 1. 

Improving Deployment Related Primary Care Provider Assessments of PTSD 
and Mental Health Conditions; 
Number of projects funded under title: 1. 

Improving Work Outcomes for Veterans with Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Incidence of Traumatic Brain Injury, Mild Traumatic Brain Injury, and 
Postconcussion Syndrome among U.S. Service Members between 1997 and 
2007; 
Number of projects funded under title: 1. 

Innovative Treatment of TBI via Regeneration of Neuronal Microtubules; 
Number of projects funded under title: 2. 

Interaction of Blast and Head Impact in the Generation of Brain 
Injuries; 
Number of projects funded under title: 1. 

Investigation of Prognostic Ability of Novel Imaging Markers for 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Kaptur Combat Mental Health Initiative: Risk and Resilience Factors 
for Combat Related Posttraumatic Psychopathology and Post Combat 
Adjustment; 
Number of projects funded under title: 1. 

Kaptur Combat Mental Health Initiative: Risk and Resilience Factors 
for Combat Related Posttraumatic Psychopathology and Post Combat 
Adjustment; 
Number of projects funded under title: 1. 

Ketamine as a Rapid Treatment for Post-Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Kevlar Vest Protection against Blast Overpressure Brain Injury: 
Systemic Contributions to Injury Etiology; 
Number of projects funded under title: 1. 

Loss of Ceruloplasmin Ferroxidase Activity Contributes to Neuronal 
Injury After Blast Exposure; 
Number of projects funded under title: 1. 

Low-Level Light Therapy for Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Measuring Blast-Related Intracranial Pressure Within the Human Head; 
Number of projects funded under title: 1. 

Measuring Intracranial Pressure and Correlation with Severity of Blast 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Mechanisms of Enhanced Fear Response after Diffuse TBI; 
Number of projects funded under title: 1. 

Medial Prefrontal Cortex and Hypothalamic-Pituitary-Adrenal (HPA) Axis 
Roles in Generation of PTSD-Like Symptoms in Spark Plasma Sintering 
(SPS) Model; 
Number of projects funded under title: 1. 

Mental Health and Resilience: Soldiers' Perceptions about 
Psychotherapy, Medication, and Barriers to Care in the United States 
Military; 
Number of projects funded under title: 1. 

Microassay Diagnostic Device for Rapid Assessment of Traumatic Brain 
Injury; 
Number of projects funded under title: 2. 

Mild TBI Following Exposure to Explosive Devices: Device 
Characteristics, Neuropsychological Functioning, and Symptoms of Post-
Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Military Blast-Related Traumatic Brain Injury: A Study of Isolated 
Shock Waves on Central Nervous System Injury; 
Number of projects funded under title: 1. 

Minocycline and N-Acetylcysteine: A Synergistic Drug Combination to 
Treat Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Mission Connect Mild TBI Translational Research Consortium; 
Number of projects funded under title: 18. 

Mission Connect Mild TBI Translational Research Consortium: Subproject 
3.5; 
Number of projects funded under title: 1. 

Molecular Mechanisms Underlying Individual Differences in Response to 
Stress in a Previously Validated Animal Model of PTSD; 
Number of projects funded under title: 1. 

Molecular Signatures and Diagnostic Biomarkers of Cumulative, Blast 
Graded Mild TBI; 
Number of projects funded under title: 1. 

MTBI Effects on Emotion Symptoms, Neurocognitive Performance, and 
Functional Impairment: A Longitudinal Study of Deployed and Non-
Deployed Army Soldiers; 
Number of projects funded under title: 1. 

Multidrug Treatment of Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Multi-Family Group Intervention for OEF/OIF Traumatic Brain Injury 
Survivors and their Families; 
Number of projects funded under title: 1. 

National Capital Consortium TBI Neuroimaging Core Project; 
Number of projects funded under title: 1. 

Neural and Behavioral Sequelae of Blast-Related Traumatic Brain Injury; 
Number of projects funded under title: 2. 

Neural Correlates of Early Intervention for PTSD; 
Number of projects funded under title: 1. 

Neural Mechanisms Linking Mild Traumatic Brain Injury and Anxiety 
States in an Animal Model; 
Number of projects funded under title: 1. 

Neural Plasticity and Neurorehabilitation Following Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Neurobehavioral Effects of Battlemind vs. Mindfulness-Based Military 
Training in Army Infantry Platoons; 
Number of projects funded under title: 1. 

Neurobiologic Evaluation of Novel Targets for Therapeutic Intervention 
in PTSD; 
Number of projects funded under title: 1. 

Neurobiology of Sleep and Sleep Treatments in PTSD (NOS-STIP); 
Number of projects funded under title: 1. 

Neurocognitive and Biomarker Evaluation of Combination mTBI from Blast 
Overpressure and Traumatic Stress; 
Number of projects funded under title: 2. 

Neuroimaging of Biomarkers for Combat Relevant Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Neuroimaging of Brain Injuries and Disorders at Cleveland Clinic; 
Number of projects funded under title: 1. 

Neuronal Targets Mediating Active Stress Coping; 
Number of projects funded under title: 1. 

Neuroprotective Strategies after Repetitive Mild Traumatic Brain 
Injury; 
Number of projects funded under title: 1. 

Neurosteroids as Critical Modulators of the Stress Response in PTSD; 
Number of projects funded under title: 1. 

Non-invasive Monitoring of Cerebral Venous Saturation in Patients with 
Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Noninvasive TBI Gravity Assessment Using a Novel Near-Infrared Diffuse 
Reflectance Imaging Approach; 
Number of projects funded under title: 1. 

Novel Methods for Identification of Concussion Associated Impairment 
in Blast Exposure Service Members; 
Number of projects funded under title: 1. 

Novel Smart Catheter for Multimodal Monitoring of the Head-Injured 
Warrior; 
Number of projects funded under title: 1. 

NWHSS: Implement Family Member Assessment Component in the Millennium 
Cohort Study; 
Number of projects funded under title: 2. 

Online PTSD Diagnosis and Treatment Training for Primary Care 
Physicians; 
Number of projects funded under title: 2. 

Opiate Masking of Stress-Induced Hypervigilance: The Cause of Delayed 
Symptom Presentation in PTSD; 
Number of projects funded under title: 1. 

Optimization and enhancement of clinical interface and clinical 
operations characteristics of the ANAM TBI assessment system; 
Number of projects funded under title: 1. 

Optimizing Screening and Risk Assessment for Suicide Risk in the U.S. 
Military; 
Number of projects funded under title: 1. 

Optimizing the Predictive Validity of the Post-Deployment Health 
Assessment/Post-Deployment Health Reassessment (PDHA/PDHRA); 
Number of projects funded under title: 1. 

Oxytocin and Social Support as Synergistic Inhibitors of Aversive Fear 
Conditioning and Fear-Potentiated Startle in Male Rats; 
Number of projects funded under title: 1. 

P11, a Biomarker for Memory Retrieval: A Possible Role in Traumatic 
Stress; 
Number of projects funded under title: 1. 

Parental Stress, PTSD, and Infant Health Outcomes in U.S. Military 
Families; 
Number of projects funded under title: 1. 

Pathogenesis of Heterotopic Ossification in Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Pathological Fingerprints, Systems Biology, and Biomarkers of Blast 
Brain Injury; 
Number of projects funded under title: 1. 

Pathophysiology of Polytrauma and Novel Treatment Strategies; 
Number of projects funded under title: 1. 

Personal Monitoring for Ambulatory PTSD Assessment; 
Number of projects funded under title: 1. 

Personalized Medicine in Veterans with Traumatic Brain Injuries; 
Number of projects funded under title: 1. 

Physical and Neuropsychiatric Trauma - Wound Healing and Tissue 
Preservation; 
Number of projects funded under title: 1. 

Physical and Neuropsychiatric Trauma Wound Healing and Tissue 
Prevention; 
Number of projects funded under title: 1. 

Physical and Psychometric Wound Healing and Tissue Prevention; 
Number of projects funded under title: 1. 

Post Concussive Rehabilitation, Treatment and Fitness for Return to 
Duty; 
Number of projects funded under title: 2. 

Post-Injury Treatment for Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Post-Stress Combined Administration of Beta-Receptor and 
Glucocorticoid Antagonists as a Novel Preventive Treatment in an 
Animal Model of PTSD; 
Number of projects funded under title: 1. 

Post-Traumatic Headache and Psychological Health: Mindfulness Training 
for Mild Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Post-Traumatic Stress Disorder and Pain Comorbidity in Veterans; 
Number of projects funded under title: 1. 

Posttraumatic Stress Disorder Co-Morbidity and the Deployment Cycle; 
Number of projects funded under title: 1. 

Posttraumatic Stress Disorder, Substance Abuse and Self Harm: 
Mediating Relationships with Respect to Combat Stress; 
Number of projects funded under title: 1. 

Prediction, Detection, and Prevention of Post-Traumatic Epilepsy and 
PTSD in Genetically Susceptible Rats; 
Number of projects funded under title: 1. 

Progesterone in the Field-Forward Treatment of Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Prophylactic Neuroprotection for Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Protein Kinase C-Epsilon in the Amygdala-Prefrontal Cortex Circuit 
Regulates the Extinction of Conditioned Fear; 
Number of projects funded under title: 1. 

Proteomic Studies of Cerebrospinal Fluid (CSF) and Plasma From 
Patients With PTSD; 
Number of projects funded under title: 1. 

PTSD Trajectory, Comorbidity, and Utilization of Mental Health 
Services Among National Guard Soldiers; 
Number of projects funded under title: 1. 

PTSD Trajectory, Comorbidity, and Utilization of Mental Health 
Services among Reserves; 
Number of projects funded under title: 1. 

Quantitative Tractography and Volumetric MRI in Blast and Blunt Force 
TBI: Predictors of Neurocognitive and Behavioral Outcome; 
Number of projects funded under title: 1. 

Regional Center of Excellence for PTSD: Phoebe Putney Memorial 
Hospital; 
Number of projects funded under title: 1. 

Reintegrating Troops with Mild Traumatic Brain Injury (mTBI) into 
Their Communities: Understanding the Scope and Timeline of Post-
Deployment Driving Problems; 
Number of projects funded under title: 1. 

Research to Improve Emotional Health and Quality of Life Among Service 
Members with Disabilities (RESTORE LIVES); 
Number of projects funded under title: 1. 

Resonance and Spectroscopy of the Human Brain in Gulf War Illness; 
Number of projects funded under title: 1. 

Resonance and Spectroscopy of the Human Brain in Gulf War Illness; 
Number of projects funded under title: 1. 

Role of MicroRNAs in the Synaptic Plasticity Dysfunction During Post-
Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Root Cause of Post-Traumatic and Development Stress Disorders; 
Number of projects funded under title: 1. 

Scaffold/Neural Stem Cells-Based Tissue Engineering in a Traumatic 
Brain Injury Model; 
Number of projects funded under title: 1. 

Sensors to Assess Pressure-Mediated Effects on Blast-Induced TBI; 
Number of projects funded under title: 1. 

Small Molecule Activators of the TRK Receptors for Neuroprotection; 
Number of projects funded under title: 1. 

Small Molecule Activators of the Tropomyosin-Receptor-Kinase (Trk) 
Receptors for Neuroprotection in TBI; 
Number of projects funded under title: 3. 

Spreading Depressions as Secondary Insults after Traumatic Injury to 
the Human Brain; 
Number of projects funded under title: 1. 

Stable Intravenous Fluorohydrocarbon Emulsion with High Oxygen 
Capacitance Combined with Hyperbaric Oxygen for the Acute Salvage of 
Tissue Injury After TBI; 
Number of projects funded under title: 1. 

Stem Cell Therapeutics for Military Relevant Brain Injury Using Amnion-
Derived Multipotent Progenitor (AMP) Cells; 
Number of projects funded under title: 1. 

Stimulant Therapy and Memory Strength: Implications for the Emergence 
and Treatment of PTSD; 
Number of projects funded under title: 1. 

Suicide Prevention Research; 
Number of projects funded under title: 1. 

TBI Effects of Marine Corp Breacher Training Program; 
Number of projects funded under title: 1. 

The Association between Suicide and OEF/OIF Deployment History; 
Number of projects funded under title: 1. 

The Effects of Hypoxia on Cognitive Function in Aviators and Complex 
System Operators that Have Had a Mild Traumatic Brain Injury; 
Number of projects funded under title: 1. 

The Effects of Explosive Blast as Compared to Post-Traumatic Stress 
Disorder on Brain Function and Structure; 
Number of projects funded under title: 1. 

The Effects of Systemic Hyperoxia and/or Hyperventilation on the 
Oxidative Injury and Cerebral Perfusion After TBI and Hemorrhage; 
Number of projects funded under title: 1. 

The International Brain Research Foundation (IBRF) Disorders of 
Consciousness (DOC) Advanced Care Protocol (ACP); 
Number of projects funded under title: 1. 

The Investigation of Emerging Technologies and Field Expedient Methods 
for Screening Traumatic Brain Injury and Tracking Initial Recovery; 
Number of projects funded under title: 1. 

The Role of Early Stress on the Development of PTSD After Blast Injury; 
Number of projects funded under title: 1. 

The Role of Microglial Subsets in Regulating Traumatic Brain Injury; 
Number of projects funded under title: 1. 

The Root Cause of Post-traumatic and Developmental Stress Disorders; 
Number of projects funded under title: 1. 

The Separate and Cumulative Effects of TBI and PTSD on Cognitive 
Function and Emotional Control; 
Number of projects funded under title: 1. 

The Soldier Medic Mettle Study; 
Number of projects funded under title: 2. 

The STRONG STAR Multidisciplinary PTSD Research Consortium; 
Number of projects funded under title: 1. 

To Support Institute of Creative Technologies (ICT) contract W911NF-04-
D-0005; 
Number of projects funded under title: 2. 

To Support Institute of Creative Technologies (ICT) contract W911NF-04-
D-0005 (follow-on fiscal year 2009 and fiscal year 2010); 
Number of projects funded under title: 1. 

Translation of Cognitive Neuroscience to Rehabilitation for Patients 
with TBI; 
Number of projects funded under title: 1. 

Traumatic Brain Injury Diffusion Magnetic Resonance Imaging Research 
Roadmap Development Project; 
Number of projects funded under title: 1. 

Treatment of TBI and Concomitant Hemorrhage With Ghrelin; 
Number of projects funded under title: 1. 

Treatment of TBI with Hormonal and Pharmacological Support, 
Preclinical Validation Using Diffuse and Mechanical TBI Animal Models; 
Number of projects funded under title: 1. 

Treatment of Traumatic Brain Injury by Localized Application of 
Subatmospheric Pressure to the Site of Cortical Impact; 
Number of projects funded under title: 1. 

Ultrahigh Resolution Retinal Imaging with Adaptive Optics for Early 
Diagnosis of Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Understanding Injury Mechanisms of Blast-Induced Neurotrauma: 
Validation of Human Injury Surrogates; 
Number of projects funded under title: 1. 

Understanding Psychological Recovery through Resilient Army National 
Guard Veterans; 
Number of projects funded under title: 1. 

Understanding Resilience in Wounded Warriors and Their Families; 
Number of projects funded under title: 1. 

Understanding the Brain Mechanism Underlying Depression in Combat-
Related Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Use of Neural Progenitor Cells and Attractive Proteins to Heal TBI; 
Number of projects funded under title: 1. 

Vagus Nerve Stimulation (VNS) and Rehabilitation in the Treatment of 
TBI; 
Number of projects funded under title: 1. 

Validation of the Single-Photon Emission Computerized Tomography 
(SPECT) Ligand CLINDE as a Marker of Microglial Activation in Baboons; 
Number of projects funded under title: 1. 

Vascularizing Bone Scaffolds for Craniofacial Reconstruction; 
Number of projects funded under title: 1. 

Veridical and Adaptive Decision Making; 
Number of projects funded under title: 1. 

Visual Information Restoration and Rehabilitation via Sensory 
Substitution Technology; 
Number of projects funded under title: 1. 

Wearable Flexible Blast Monitor; 
Number of projects funded under title: 1. 

When Good Memory Mechanisms Go Bad: Toward an Understanding of the 
Role of Protein Kinase C (PKM)-Zeta in Post-Traumatic Stress Disorder; 
Number of projects funded under title: 1. 

Xenon as a Neuroprotectant in Traumatic Brain Injury; 
Number of projects funded under title: 1. 

Total; 
Number of projects funded under title: 397. 

Source: Army Medical Research and Materiel Command. 

[End of table] 

[End of section] 

Appendix IV: Examples Provided by the Army Medical Research and 
Materiel Command of Ongoing Research That Was Representative of 
Positive Results Achieved to Date: 

In providing us with lists of PH and TBI research projects, officials 
at the Army Medical Research and Materiel Command cited three 
projects, in particular, that they indicated were representative of 
positive results achieved to date: the Biomarker Assessment for 
Neurotrauma Diagnosis and Improved Triage System; clinical testing of 
NNZ-2566, a drug to treat patients who experience TBI; and protocols 
and guidelines for developing refined medical imaging that can detect 
TBI. 

The first, the Biomarker Assessment for Neurotrauma Diagnosis and 
Improved Triage System (BANDITS), is an example of a Research and 
Technology Development project. According to information provided by 
the Army, no approved test to objectively diagnose mild TBI exists, 
and the aim of the BANDITS program is to develop a blood test to 
detect brain cell damage. Three systems to measure blood samples are 
anticipated. The first would be a bench-top system about the size of a 
large printer and would be deployable only with larger battlefield 
medical units. The second system would be smaller, approximately the 
size of a loaf of bread, and thus more easily deployable. The third 
system would be a hand-held, battery-powered device deployable with 
individual medics. Figure 2 depicts one of the systems. According to 
information provided by the Army, in a limited trial of fewer than 100 
patients, the BANDITS program has achieved levels of accuracy 
equivalent to those of medical tests currently relied on to detect 
heart damage and prostate cancer. The Army is continuing clinical 
trials for Food and Drug Administration licensure and expects to 
complete them in 2013. 

Figure 2: System Anticipated from the Army's Biomarker Assessment: 

[Refer to PDF for image: photograph] 

Bench-Top. 

Source: DOD. 

[End of figure] 

The second project entails clinical testing of a potential drug 
treatment for TBI and is an example of a Clinical Research and 
Development project. According to information provided by the Army, no 
approved drug yet exists to treat TBI, and the aim of the project is 
to develop NNZ-2566, a drug candidate that could reduce death and 
disability from moderate to severe TBI and speed recovery from mild 
TBI. An intravenous form of the drug has been developed for moderate 
to severe TBI patients, and an oral formulation will be developed for 
mild TBI patients. NNZ-2566 was found to be safe in humans in its 
initial clinical trial and is currently undergoing a larger 
intermediate trial to see if it will reduce the effects of TBI damage. 
If that trial is successful, a final large trial will be completed 
with the hope of approval by the Food and Drug Administration by 2016. 
Figure 3 depicts the difference between a brain with penetrating brain 
injury that receives no treatment and a brain that does receive 
treatment with NNZ-2256. 

Figure 3: Brain Imagery Demonstrating the Impact of Treatment with NNZ-
2256: 

[Refer to PDF for image: 2 scans] 

No treatment; 
Treated with NNZ-2256. 

Source: DOD. 

[End of figure] 

The third RDT&E project that Army Medical Research and Materiel 
Command officials cited entails protocols and guidelines for 
developing refined medical imaging that can detect TBI. According to 
the Army, no approved test exists that can objectively diagnose TBI. 
Currently, the diagnosis of TBI is made by assessing symptoms, such as 
fatigue, headaches, visual disturbances, memory loss, poor 
attention/concentration, sleep disturbances, and the loss of balance. 
Using a high-powered magnetic resonance imaging (MRI) machine, Army 
researchers have developed an advanced imaging protocol that produces 
41,000 images of the brain; standard MRIs of the brain produce 350 
images. The added images are computer enhanced to show brain lesions 
undetectable with standard medical imaging approaches. Going forward, 
the effort is intended to develop a new standardized imaging protocol 
that can be achieved on existing medical imaging machines routinely 
found in medical centers. Using the new protocol, 64 percent of 
patients with normal computer tomography (CT) and MRI scans were shown 
to have MRI findings of trauma. Figure 4 displays the differences 
among CT, routine MRI, and advanced protocol MRI scans. 

Figure 4: Differences among CT, Routine MRI, and Advanced Protocol MRI 
Scans: 

[Refer to PDF for image: 3 scans] 

CT scan: read as normal; 
MRI: Read as possible lesion; 
Advance Protocol MRI: Read as multiple lesions. 

Source: DOD. 

[End of figure] 

[End of section] 

Appendix V: Comments from the Department of Defense: 

The Assistant Secretary of Defense: 
Health Affairs: 
Defense Pentagon: 
Washington, DC 20301-1200: 

January 13, 2012: 

Ms. Brenda Farrell: 
Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Ms. Farrell: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) Draft Report, GAO-12-154, "Defense Health: 
Coordinating Authority Needed for Psychological Health and Traumatic 
Brain Injury Activities,” received on December 1, 2011, (GAO Code 
#351513). Overall the Department concurs with the recommendations
made in this report. Regarding the second recommendation, Health 
Affairs will work with other organizations in the department to 
address concerns regarding reliability of obligations and expenditure 
data. The Department of the Army provided comments and technical 
corrections, which have been incorporated into our response. 

Thank you for the opportunity to review and provide comments. The 
points of contact on this issue are Mr. Ronald Henke (Functional) and 
Mr. Gunther Zimmerman (Audit Liaison). Mr. Henke may be reached at 
703) 681-3726, or Ronald.Henke@tma.osd.mil. Mr. Zimmerman may be 
reached at (703) 681-4360, or Gunther.Zimmerman@tma.osd.mil. 

Sincerely, 

Signed by: 

Jonathan Woodson, M.D. 

Enclosures: As stated. 

[End of letter] 

Government Accountability Office (GAO) Draft Report: 
Dated December 1, 2011: 
(GAO Code #351513/GAO-12-154) 

"Defense Health: Coordinating Authority Needed For Psychological 
Health And Traumatic Brain Injury Inquiries" 

Department Of Defense Comments To The Recommendations: 

To increase visibility over how Department of Defense (DoD) is 
spending appropriated funds to address Psychological Health (PH) and 
Traumatic Brain Injury (TBI) conditions, we recommend that the 
Secretary of Defense direct the Assistant Secretary of Defense for 
Health Affairs to take the following four actions: 

Recommendation #1: Include expenditures for PH and TBI activities in 
annual reports to Congress as directed by Section 1634 of the National 
Defense Authorization Act for Fiscal Year 2008. 

DoD Response: Concur. Although expenditure data often lags the end of 
the year by many months, we will include expenditure information that 
is available at the time we must submit the annual PH and TBI reports. 

Recommendation #2: Develop, maintain, and coordinate quality control 
mechanisms that help ensure that the obligation and expenditure data 
they report on PH and TBI projects and research are complete and 
accurate. 

DoD Response: Concur with comments. DoD agrees it would be preferable 
to obtain all fiscal data from a single source to allow for 
confirmation of data reliability. Unfortunately, the DoD accounting 
structure does not allow for a single system of accumulating and 
reporting fiscal data. Health Affairs/TRICARE Management Activity 
recognizes its responsibility for maintaining and reporting accurate 
fiscal data relating the TBI/PH program, and will take steps to 
improve the accuracy and reliability of the data where possible. 

Recommendation #3: If patient costs are provided in future annual 
reports, clearly show what is included and not included for all 
patient costs; and; 

DoD Response: Concur. The patient data provided in previous years was 
intended to be informative. However, acknowledging that it may have 
been confusing and recognizing our limited ability to provide the 
detail desired by the GAO, we will omit this information in future 
reports. 

Recommendation #4: Revisit Defense Centers of Excellence (DCoE's) role 
as DoD's coordinating authority for issues concerning its PH and TBI, 
as stated in its own plan, and determine whether it or another 
organization should perform this function. 

DoD Response: Concur. DCoE's role has evolved over time. The DoD 
Strategic Approach for Staffing, Resourcing, and Sustainment of 
Medical Centers of Excellence (CoE) report to Congress submitted in 
April 2011 described the future strategy for Centers of Excellence, 
including DCoE, to provide the highest quality of care for our Service 
members and our other beneficiaries. It outlined the role of the DCoE 
to focus on associated and well-defined groups of clinical conditions 
and achieve improvement in clinical outcomes through clinical, 
educational, and research activities. 

The "revisit" of DCoE's role is underway. A CoE Advisory Board, which 
is part of the Military Health System's governance structure, is 
overseeing the development of a revised and detailed Concept of 
Operations for DCoE The Board directed the DCoE to develop "Pathways 
of Care for Post-Traumatic Stress Disorder and Depression" covering 
the spectrum from prevention through reintegration or transition and 
lead the development of clinical guidance, measures of effectiveness, 
educational materials, identification of research priorities, and 
strategies for improving access to care. Among other initiatives, 
DoD's Cost Assessment and Program Evaluation office requested that 
DCoE assume a larger role in psychological health and traumatic brain 
injury program evaluation. 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Brenda S. Farrell, Director, (202) 512-3604 or farrellb@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Revae Moran, Acting Director; 
David E. Moser and Marilyn Wasleski, Assistant Directors; Geraldine 
Beard; Karen Nicole Harms; Travis Hill; LaToya Jeanita King; Felicia 
Lopez; Grant Mallie; Charles Perdue; Beverly C. Schladt; Michael 
Silver; Amie Steele; Cheryl A. Weissman; and Ricardo A. Marquez made 
key contributions to this report. 

[End of section] 

Related GAO Products: 

VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, 
and Efforts to Increase Access. [hyperlink, 
http://www.gao.gov/products/GAO-12-12]. Washington, DC: Oct. 14, 2011. 

DOD and VA Health Care: Action Needed to Strengthen Integration across 
Care Coordination and Case Management Programs. [hyperlink, 
http://www.gao.gov/products/GAO-12-129T]. Washington, DC: Oct. 6, 2011. 

Defense Centers of Excellence: Limited Budget and Performance 
Information on the Center for Psychological Health and Traumatic Brain 
Injury. [hyperlink, http://www.gao.gov/products/GAO-11-611]. 
Washington, DC: June 30, 2011. 

DOD and VA Health Care: Federal Recovery Coordination Program 
Continues to Expand but Faces Significant Challenges. [hyperlink, 
http://www.gao.gov/products/GAO-11-250]. Washington, DC: Mar. 23. 2011. 

Defense Health: Management Weaknesses at Defense Centers of Excellence 
for Psychological Health and Traumatic Brain Injury Require Attention. 
[hyperlink, http://www.gao.gov/products/GAO-11-219]. Washington, DC: 
Feb. 28, 2011. 

VA Health Care: Progress and Challenges in Conducting the National 
Vietnam Veterans Longitudinal Study. [hyperlink, 
http://www.gao.gov/products/GAO-10-658T]. Washington, DC: May 5, 2010. 

VA Health Care: Status of VA's Approach in Conducting the National 
Vietnam Veterans Longitudinal Study. [hyperlink, 
http://www.gao.gov/products/GAO-10-578R]. Washington, DC: May 5, 2010. 

VA Health Care: Preliminary Findings on VA's Provision of Health Care 
Services to Women Veterans. [hyperlink, 
http://www.gao.gov/products/GAO-09-899T]. Washington, DC: July 16, 
2009: 

DOD and VA Health Care: Challenges Encountered by Injured 
Servicemembers during Their Recovery Process. [hyperlink, 
http://www.gao.gov/products/GAO-07-589T]. Washington, DC: March 5, 
2007. 

VA Health Care: Spending for Mental Health Strategic Plan Initiatives 
Was Substantially Less Than Planned. [hyperlink, 
http://www.gao.gov/products/GAO-07-66]. Washington, DC: November 21, 
2006. 

VA Health Care: Preliminary Information on Resources Allocated for 
Mental Health Strategic Plan Initiatives. [hyperlink, 
http://www.gao.gov/products/GAO-06-1119T]. Washington, DC: September 
28, 2006. 

VA Health Care: VA Should Expedite the Implementation of 
Recommendations Needed to Improve Post-Traumatic Stress Disorder 
Services. [hyperlink, http://www.gao.gov/products/GAO-05-287]. 
Washington, DC: February 14, 2005. 

VA and Defense Health Care: More Information Needed to Determine If VA 
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder 
Services. [hyperlink, http://www.gao.gov/products/GAO-04-1069]. 
Washington, DC: September 20, 2004. 

[End of section] 

Footnotes: 

[1] Dana Priest and Anne Hull, "Soldiers Face Neglect, Frustration at 
Army's Top Medical Facility," Washington Post (Feb. 18, 2007). 

[2] The reports include the Independent Review Group, Rebuilding the 
Trust: Report on Rehabilitative Care and Administrative Processes at 
Walter Reed Army Medical Center and National Naval Medical Center 
(April 2007); Task Force on Returning Global War on Terror Heroes, 
Report to the President (April 2007); Department of Defense Task Force 
on Mental Health, An Achievable Vision: Report of the Department of 
Defense Task Force on Mental Health (June 2007); President's 
Commission on Care for America's Returning Wounded Warriors, Serve, 
Support, Simplify (July 2007); Veterans' Disability Benefits 
Commission, Honoring the Call to Duty: Veterans' Disability Benefits 
in the 21st Century (October 2007); and Inspectors General, Department 
of Defense, Department of Veterans Affairs, DOD/VA Care Transition 
Process for Service Members Injured in OIF/OEF (Operation Iraqi 
Freedom/Operation Enduring Freedom) (June 2008). 

[3] U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq 
Accountability Appropriations Act, 2007, Pub. L. No. 110-28 (2007), 
121 Stat. 134. 

[4] Pub. L. No. 110-181 §§ 1621, 1622 (2008). 

[5] The TRICARE Management Activity oversees DOD's medical and dental 
programs and manages and executes the Defense Health Program 
appropriation. The Director of the TRICARE Management Activity reports 
to the Assistant Secretary of Defense for Health Affairs. TRICARE 
Management Activity's associated programs, resources, and functions 
include the Uniformed Services University of the Health Sciences, the 
Armed Forces Radiobiology Research Institute, and DCOE. 

[6] In conducting prior work in this area, GAO compared Defense Center 
of Excellence for Psychological Health and Traumatic Brain Injury 
obligations recorded by TRICARE Management Activity to supporting 
documentation and found that, while the date and amount of obligations 
were properly recorded, there were problems at the subobject 
classification level for fiscal year 2009. See GAO, Defense Health: 
Management Weaknesses at Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury Require Attention, 
[hyperlink, http://www.gao.gov/products/GAO-11-219] (Washington, DC: 
Feb. 28, 2011). 

[7] The salaries of military medical personnel are funded through the 
services' Military Personnel appropriations and are therefore not 
included in the costs we have calculated in this report related to 
care for servicemembers with PH-and TBI-related conditions. 

[8] For example, certain O&M amounts appropriated for the Defense 
Health Program by the Department of Defense Appropriations Act of for 
fiscal year 2010 were made available for obligation for longer than 
one fiscal year. Pub. L. No. 111-118, 123 Stat. 3424 (2009). 

[9] GAO, Defense Health: Management Weaknesses at Defense Centers of 
Excellence for Psychological Health and Traumatic Brain Injury Require 
Attention, [hyperlink, http://www.gao.gov/products/GAO-11-219] 
(Washington, DC: Feb. 28, 2011) and GAO, Defense Centers of 
Excellence: Limited Budget and Performance Information on the Center 
for Psychological Health and Traumatic Brain Injury, [hyperlink, 
http://www.gao.gov/products/GAO-11-611] (Washington, DC: June 30, 
2011). 

[10] Pub. L. No. 110-181, §§ 1621-1622 (2008). 

[11] Congressionally directed DOD allocations for PH and TBI were 
included in explanatory statements and committee reports accompanying 
the respective public laws. In the case of large programs, funds are 
sometimes appropriated specifically for the program in question, 
either directly in the Appropriations Act or through incorporation by 
reference to sections of the relevant conference report. However, 
funds for a given program may also be included in a lump sum 
appropriation rather than being specifically appropriated for that 
program. Conference reports (and committee reports) often contain 
program-by-program funding information, but these congressional 
directions do not ordinarily create a legally binding subdivision of 
funds unless they have been incorporated by reference into the 
relevant Appropriation Act. Our totals represent funds specifically 
appropriated or otherwise designated by the DOD for PH and TBI 
activities out of lump sum appropriations. 

[12] Although the National Defense Authorization Act for Fiscal Year 
2008 directed DOD to establish a center of excellence for TBI and a 
center of excellence for PTSD and other mental health conditions, DOD 
established one center covering TBI and psychological health, which 
includes post-traumatic stress disorder. Congress, in fiscal year 2008 
expanded the use of funding for post-traumatic stress disorder to 
include psychological health. 

[13] Pub. L. No. 110-181 § 1634 (2008). 

[14] GAO, Defense Centers of Excellence: Limited Budget and 
Performance Information on the Center for Psychological Health and 
Traumatic Brain Injury, [hyperlink, 
http://www.gao.gov/products/GAO-11-611] (Washington, DC: June 30, 
2011). 

[15] To determine data reliability, we drafted and distributed a data 
reliability assessment questionnaire to DOD entities that provided us 
financial and project information. For additional information, see 
appendix I. 

[16] The Under Secretary of Defense (Comptroller)/Chief Financial 
Officer has acknowledged that DOD financial management systems do not 
substantially comply with federal financial management system 
requirements, U.S. generally accepted accounting principles, and the 
U.S. Government Standard General Ledger at the transaction level. 

[17] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] 
(Washington, DC: November 1999). 

[18] We were unable to obtain data for fiscal years 2007 and 2008. 
TRICARE Management Activity distributed supplemental funds 
appropriated in 2007 as a 2-year appropriation for fiscal years 2007 
and 2008. According to service officials, obligations and 
distributions were thus recorded and tracked as combined fiscal year 
2007/2008 transactions, rather than separate fiscal years 2007 and 
2008 transactions. 

[19] We note, however, that both the DOD Inspector General and GAO 
have identified weaknesses in these reported obligation data. 

[20] Of the 177 separate PH and TBI projects, 102 projects spanned 
both fiscal years 2009 and 2010. 

[21] The Department of the Navy includes the Navy and the Marine Corps. 

[22] Computed tomography scanning is the imaging of anatomical 
information from a cross-sectional plane of the body, each image 
generated by a computer synthesis of x-ray transmission data obtained 
in many different directions in a given plane. 

[23] Pub. L. No. 110-181 §§ 1621-1622 (2008). PTSD was later 
incorporated into the category of psychological health. 

[24] Report to Congress in Response to the National Defense 
Authorization Act for Fiscal Year 2008, Section 1618, Comprehensive 
Plan on Prevention, Diagnosis, Mitigation, Treatment, and 
Rehabilitation of, and Research on, Traumatic Brain Injury, Post-
Traumatic Stress Disorder, and Other Mental Health Conditions in 
Members of the Armed Forces (Oct. 31, 2008). 

[25] This Committee was established by the Secretaries of Defense and 
Veterans Affairs in 2007 to make recommendations for existing policies 
on the coordination and sharing of resources between DOD and the 
Department of Veterans Affairs. 

[26] According to DOD Directive 5136.01, the Office of the Assistant 
Secretary of Defense for Health Affairs is responsible for ensuring 
the effective execution of DOD's medical mission, and, in carrying out 
that responsibility, is required to exercise authority, direction, and 
control over funding and other resources, which would include funds 
used for PH and TBI. 

[27] National Defense Authorization Act for Fiscal Year 2006, Pub. L. 
No. 109-163, § 256 (2006). 

[28] Department of Defense Directive 6025.21E, Medical Research for 
Prevention, Mitigation, and Treatment of Blast Injuries (July 5, 2006). 

[29] RAND, Programs Addressing Psychological Health and Traumatic 
Brain Injury Among U.S. Military Servicemembers and Their Families 
(Arlington, VA: 2011). 

[30] Report on Establishment of Centers of Excellence: Report to 
Congress, DoD/VA Wounded, Ill, and Injured Senior Oversight Committee 
(Nov. 19, 2008). 

[31] Report to Congress in Response to the National Defense 
Authorization Act for Fiscal Year 2008, Section 1618, Comprehensive 
Plan on Prevention, Diagnosis, Mitigation, Treatment, and 
Rehabilitation of, and Research on, Traumatic Brain Injury, Post-
Traumatic Stress Disorder, and other Mental Health Conditions in 
Members of the Armed Forces (Oct. 31, 2008). 

[32] National Defense Authorization Act for Fiscal Year 2004, Pub. L. 
No. 108-136 § 583 (Nov. 24, 2003), codified at 38 U.S.C. § 320. 

[33] In conducting prior work in this area, the GAO team tested DCOE 
obligations recorded by TMA for DCOE to supporting documentation and 
found that while the date and amount of obligations were properly 
recorded, there were problems at the subobject classification level 
for fiscal year 2009. See Defense Health: Management Weaknesses at 
Defense Centers of Excellence for Psychological Health and Traumatic 
Brain Injury Require Attention, [hyperlink, 
http://www.gao.gov/products/GAO-11-219] (Washington, DC: Feb. 28, 
2011). See also GAO, DOD Financial Management: Weaknesses in Controls 
over the Use of Public Funds and Related Improper Payments, 
[hyperlink, http://www.gao.gov/products/GAO-11-950T] (Washington, DC: 
Sept. 22, 2011) and DOD Financial Management: Improvements Are Needed 
in Antideficiency Act Controls and Investigations, [hyperlink, 
http://www.gao.gov/products/GAO-08-1063] (Washington, DC: Sept. 26, 
2008) and Department of Defense Office of Inspector General, 
Independent Auditor's Report on the DOD Agency wide FY 2010 and 2009 
Basic Financial Statements, Report D-2011-013 (Arlington, VA: Nov. 15, 
2010). 

[End of section] 

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